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RICHMOND        VIRGINIA 


V*  A<\*-*r** 


^LxSTl  &++&+ ~fj~/z.&y 


MILITARY  SURGERY, 


FOR    THK    USE    OF 


SURGEONS  IN  THK  CONFEDERATE  STATES  ARMY; 


oHplanafonr  pates  jjJ[  all  Isrful  derations. 


BY 

J.  JULIAN  CHISOLM,  M.D., 

PROFESSOR  OK  SURGERY  IK  THK   HEDICAL  COLLEGE  OF  SOUTH  CAROLINA, 
i   RQEON   IN  THK  CONFEDERATE  STATUS  ARMY,   ETC. 


THIRD  l:PITI»>     f'ARKFI'LLT  REVISED  AND  IMPROVED. 


COLUMBIA: 
F.VAXS    AND   COGS  WEI   I 
1864 


Entere  1  according  to  Ad  of  Congress,  Id  the  yeai  1864,  bj 

J.    J.    CHI80LM,    M.H.. 

In  the  Clerk's  office  "f  the  Dist iict  Court  of  tlic  Confederate   States   for   the 

District  of  Booth  Caroline* 


Kvank  4  Cooswr.i  l.  Printers,  Colombia,  8,  C, 


HS.2L 


SAMUEL   PRESTON   MOORE,   C.    S.    A., 


Sl'Rr.EON-UBNKRAI,   OF    TUB   CONFEDERATE    STATUS    ARMT, 


IN    APPRECIATION    or    THE    VERY    EPFICIEN1     MANNER    IN    ivhii  n    HE 


HAS    AHIlANIItn    AND    CONDUCTED    THE    BEST    OHGANIZET1    OF 


ALL    THE   J'EPAKTMENTS    OK    Ml  R    AKMY.    THIE 


BOOK    rS    RESPECTFULLY 


hli>i>  A  i  El' 


PREFACE  TO  FIRST  EDITION. 


In  putting  forth  this  Manual  of  Military  Surgery  for  the  use 
of  Surgeons  in  the  Confederate  service,  I  have  been  led  by  the 
desire  to  mitigate,  if  possible,  the  horrors  of  war,  as  seen  in  its 
most  frightful  phase  in  military  hospitals.  As  our  entire  army 
is  made  up  of  volunteers  from  every  walk  of  life,  so  we  find  the 
surgical  staff  of  the  army  composed  of  physicians  without  sur- 
gical experience.  Most  of  those  who  now  compose  the  surgical 
staff  were  general  practitioners,  whose  country  circuit  gave 
them  but  little  surgery,  and  very  seldom  presented  a  gunshot 
wound.  As  our  country  had  been  enjoying  an  uninterrupted 
state  of  peace,  the  collecting  of  large  bodies  of  men,  and  retain- 
ing them  in  health,  or  the  hygiene  of  armies,  had  been  a  study 
without  an  object,  and,  therefore,  without  interest.  When 
the  war  suddenly  broke  upon  us,  followed  immediately  by  the 
blockading  of  our  ports,  all  communication  was  cut  off  with 
Europe,  which  was  the  expected  source  of  our  surgical  informa- 
tion. As  there  had  been  no  previous  demand  for  works  on  mil- 
itary surgery,  there  were  none  to  be  had  in  the  country,  and  our 
physicians  were  compelled  to  follow  the  army  to  the  battle  with- 
out instruction.  No  work  on  military  surgery  could  be  pur- 
chased in  the  Confederate  States.  As  military  surgery,  which 
is  one  of  expediency,  differs  so  much  from  civil  practice,  the 
want  of  proper  information  has  already  made  itself  seriously  felt. 
In  times  of  war,  where  invasion  threatens,  every  citizen  is  ex- 
pected to  do  his  duty  to  his  state.  1  saw  no  better  means  of 
showing  my  willingness  to  enlist  in  the  cause  than  by  preparing 
a  manual  of  instruction  for  the  use  of  the  army,  which  might  be 
the  means  of  saving  the  lives  and  preventing  the  mutilation  of 
many  friends  and  countrymen.  The  present  volume  contains 
the  fruit  of  European  experience,  as  dearly  purchased  in  re- 
cent campaigning.     Besides  embodying  the  experience  of  the 


VI  PREF  \'  I 

masters  in  military  surgery  as  to  the  treatment  of  wounds,  I 
have  incorporated  chapters  upon  the  food,  clothing,  and  hygiene 

of  troops;  with  directions  how  the  health  of  an  army  is  to  be 
preserved,  and  how  an  effective  strength  i*  to  1"  sustained; 
also,  the  duties  of  military  Burgeons,  both  in  th>'  camp  ami  iu  the 
field.  In  preparing  this  volume,  I  have  not  hesitated  to  add  to 
my  own  experience,  in  the  treatment  of  surgical  injuries  any 
useful  information  which  I  could  obtain  from  the  most  recent 
German,  French,  and  English  works  on  military  surgery  ;  and 
in  many  instances,  where  the  language  used  by  them  expressed 
tu  the  point  the  subject  under  discussion,  I  have  not  hesitated 
to  transfer  entire  sentences  directly  to  these  pages.  I  make 
this  acknowledgment  en  masse  6f  the  very  liberal  use  of  the 
following  works,  as  quotation  marks  were  sometimes  over- 
looked : 

Maximen  der  Kriegsheilkunst,  von  L.  Stromycr,  Hanover, 
L855;  Supplement  der  Maximen  der  Kriegsheilkunst,  von  L. 
Stromyer,  Hanover,  I860;  Loeffler  Behandlung  der  Schuss- 
wunde,  Berlin,  1859;  Histoire  MeMicc-Chirurgicale  dela  Guerre 
de  Crime*e,  par  le  Docteur  Adolphe  Armarid,  1'aris,  1858;  La 
Guerre  de  Crimee,  par  L.  Baudens,  Paris,  1858;  I>es  Plaiea 
d'Armes  a  feu;  Communications —  Paites  a  l'Acade*mie  Nation- 
ale  de  Medicine, 'Paris,  1849;  Notesof  the  Wounded,  from  the 
Mutiny  in  India,  by  George  Williamson,  London,  1859;  Coles' 
Military  Surgery,  with  Experience  of  Field  Practice  in  India", 
London.  1852;  Gunshot  Wounds  of  the  Chest,  by  Patrick  Fra- 
Ber,  M.D.,  London,  lx.r>y;  Guthrie's  Commentaries  on  Military 
Surgery,  London,  1855;  McLeod'a  Note,  on  the  Surgery  of  the 
Crimean  War,  London,  1858;  Hennen's  Principles  of  Military 
Surgery;  Lairey's  .Military  Surgery;  Ballingall's  Outlines  of 
Military  Surgery  ;  Gross'  System  of  Surgery  ;  Erichsen's  Science 
and  Art.  of  Surgery  ;  Jackson  on  the  Formation.  Discipline,  and 
Economy  of  Annies:  SeMilot, Medicine  Operatoire,  Paris,  1859  ; 
A  Practical  Treatise  on  Military  Surgery,  by  F.  II.  Hamilton, 
M  I>.,  New  York,  18C1;  Report  Medical  Department  (Army) 
ordered  by  the  Bouse  of  Commons  to  be  printed,  July  3,  isotj; 
Gavin  on  Feigned  Diseases,  London,  1848. 

August,  1861. 


PREFACE  TO  THE  THIRD  EDITION. 


After  three  years  of  incessant  and  bloody  warfare  I  have  been 
called  upon  to  embody,  in  a  new  edition  of  "  The  Manual  of  Mil- 
itary Surgery,"  the  large  experience  of  the  medical  staff  of  our 
army.  It  has  been  my  aim  to  condense,  in  a  concise,  practic.il 
form,  the  improvements  in  the  treatment  of  gunshot  wounds  which 
have  been  developed  during  our  active  campaigns,  and  repeated- 
ly confirmed  upon  thousands  of  wounded.  In  collecting  this  ex- 
perience, I  am  under  heavy  obligation  to  my  friend,  Surgeon 
II.  Baer,  P.  A.  C.  S.,  who  was  kindly  permitted  by  Surgeon  F. 
Sorrel,  C.  S.  A.,  the  accomplished  and  efficient  Inspector-General 
of  Hospitals,  to  collate  for  me  condensed  tabulated  reports  of  all 
the  papers  in  his  office,  comprising  the  official  reports  of  all  the 
hospital  and  field  surgeons  of  the  Confederate  army.  Only 
those  who  have  undertaken  to  tabulate  statistics  can  appreciate 
the  labor  of  Surgeon  Baer.  Through  his  assiduity  we  have  an 
opportunity  of  contrasting  our  surgical  experience  with  that  of 
European  armies.  An  examination  of  these  tables  will  show  to 
what  proficiency  surgery  has  attained  in  the  Confederate 
States. 

June,  10,  1864.  J.  J.  CHISOLM. 


I  N  1  >  E  X 


A.  Page. 

Abdominal    wounds 887 

viscera,  rupture  of .">:">  I 

Abscess  on  the  brain 297 

Accident  to  stumps -421 

Ambulance  corps 112 

corps  in  tbe  Prencb  service '  1-1 

wagons   1 04 

Amusements  in  camp 57 

Amputation  at  ankle-joint 471 

of  arms 46fi 

at  elbow-joint -102 

of  foot    4  72 

of  forearm 169 

of  finger I.r>l 

of  band 4.r>7 

at  bip-joint is:', 

at  knee-joint I. so 

of  leg 1 7  ('» 

modes  of  operating 117 

necessity  for 409 

necessary  in  secondary  hemorrhage 212 

primary ::fi(l 

at  shoulder-joint 409 

table  of .111! 

of  tbigb IM 

of  toes 4  71 

treatment  after l2o 

Anal  fistula .ri2:> 

Anchylosis i:;;. 

Ankle-joint,  injury  to IDs 

ion  of I'.is 

Annual  allowance  of  clothing 2-> 

Anterior  wire  splint  of  Smith .".'.'7 

Appearance  of  gunshot  wounds 167 


X  INDEX 

Arm.  amputation  <>f 

treatment  iu  inn-tun-  of 

:    lit-iii<.rrh:i^e 168 

4^'.' 

i\ill:ir\ .  ligature  ol 

carotid,  ligature  of .'iU^ 

1 1.  ligature  of ">1 1 

femoral,  ligature  of >lfi 

fibular,  ligature  of 614 

humeral,  ligature  of 

iliac,  ligature  of 51  s 

I  Ingual,  ligature  of 511 

radial,  ligature  of 504 

.-n  l 'i-l  a  via  n,  ligature  of 507 

superior  thyroid,  ligature  of BIO 

tibial)    ligature  of 513 

ulna,  ligature  of 503 

gimeotal  surgoon,  duties  of 128 

hospital  lurgeon,  duties  of 88 

a  general  hospital 88 

in  Beld  hospital C:( 

Axillary  artery,    ligation  "I 

U. 

for  trnopi :i7 

Balls,  dei  lation  of 168 

Bit  of 

D   Of I-l 

Battening  ol 101 

Boding  ol 161 

rorrepi IU 

incarceration  <>t 166 

in  peh  !•■  r.ivin 

866 

I  !  Ill  V 1  I  B 

Battle-flold 1  88 

medloal  mppliat  t"i 168 

i..  nt  ..i  grounds  on 166 

Bayonet  wi.un.l- 'J  I .; 



...t  in  hospitals si 

ite 86 

Bivonae 17 

Bladder,  gunsbol  wound  "I 


IN'hF.X  XI 

Bleeding  vessels,  how  found 207 

Brachial  artery,  ligation  of 50.5 

Brain,  abscess  on '. 297 

concussion  of. .- 274 

foreign  bodies  in .  .299 

compression  of 27 S 

hemorrhage  on 2S7 

inflammation  of 285 

Boots  of  soldier 22 

Bread   in  the  army 88 

C. 

Cacolet  of  the  French  army i  . . .      104 

Cam] 4S 

amusements    in ,r>7 

cleanliness  of ,ri] 

duties  of  surgeon 121 

employment  in 55 

Caloric  properties  of  clothing 17 

Capacity  of  hospitals Sli 

Carotid  artery,   ligation  of ."ills 

Causes  of  secondary  hemorrhage 20fi 

Cerebral  inflammation,  treatment  of 2*.> 

Chest  wounds .;  1 1 

Chloroform \^~ 

Ch opart's  amputation  of  foot 473 

Clavicle,  resection  of 4S9 

Cleanliness  necessary  to  health 2S 

in  hospitals S7 

Clerks,  duties  of  in  general  hospitals CVI 

Clothiug  for  troops 20 

physiology  of I ; 

issued    to  soldiers 25 

-upply  necessary  to  health 20 

particles  in  wound Ms 

C>>at  of  soldiers 20 

Code  of  regulations  in  general  hospital 22 

Coffee  for  soldiers .',2 

Cold,  effects  of i:;; 

Cold  water  treatment  in  gunshot  irouuds 1 93 

Color   of  clothing 21 

Compound  fractures 

fracture  of  arm 

h  .i'  lure  ol  leg 107 


Ml  1\|.|\ 

Compound- fractures  o|  thigh 

Compression  "t  brain l'7* 

Cononsston  <<f  l>r:iin i'7 ! 

Confederate  urmv  medical  stall I"*: 

i  'onfederate  biscuit 

< !onical  balls,  effeeti  <•> 1 1<» 

itum] 426 

ripti I 

rlpl  net Ifi 

Contracted  limbi 432 

Cooking  Dtensili  in  Confederate  army it 

D. 

Danger  "f  an  Inearoerated  ball 180 

-inn  of  skull 280 

Deviation  of  balls 182 

Dieting  <>i  patients  in  hospital M 

Diet-table  for  hospitals BJ 

Disarticulation  ;it  elbow-joinl 168 

hi  bip-joinl 

Ill  lilll'C-jllillt 

at  shoulder-join  I MSB 

:ii  mrlst  joint 458 

Discipline  in  general  hospital 7" 

Disturbing  influences  of  wounds 2(>1 

Disinfection  of  hospitals 60 

■founds 183 

Duties  "i  :i  sistant  regimental  surgeon 129 

of  inn uli ii  hi  no rps IIS 

iatanl  hospital  surgeon »'.  s 

ul  chief  surgeon  in  general  hospital BIB 

of  chief  matron 77 

of  clerks  in  general  hospital '. lii* 

of  division  surgeon W 

<>r  hospital  stewards 79 

of  nm  see  in  genera]  hospital 74 

■  I  patient    in  general  hospital    7'.' 

of  hospital  sergeant 79 

of  surgeon  on  the  battle-field 182 

ol  surgeon  at  field  infii  mar; 140 

of  regimental  surgeon  In  earn] 121 

■  ■I  surgi i  in  Prussian  army U8 

of  ward-maste]  in  general  hospital IS 


'Ml    S 


Effects  of  conical   balls Il'.l 

of  spent-balls 355 

Elbow-joint,  amputation  of 463 

resection  of 386 

operation  of  resection I '.):; 

Employment  in  camp 55 

Encampment 48 

Enderinie  use  of  morphine 222 

English  losses  in  Crimea II 

English  army  medical  staff Ill) 

Entrance  of  balls 159 

Enrolling  service 15 

Equipment  of  soldier 27 

Erysipelas 22<> 

Examination  of  wounds 172 

of  wounds  at  field  infirmary L49 

of  recruits 13 

Exit  of  balls 1 59 

Exposure  in  open  air 6 

Exposure  of  troops  from  rural  districts  to  diseases 2 

Extraction  of  balls 181 

F.    . 

Face  wounds. , , 302 

Facial  artery,  ligation  of oil 

Feigning  disease Ill 

Female  nurses  in  hospitals 03 

I'Vvcr,  hectic 25. > 

Femur,  compound  fracture  of $95 

Femoral  artery,  ligation  of >\> 

Fibular  artery,  ligation  of 514 

Field  duties  of  surgeon 1  I  o 

Field  infirmaries,  organization  of 1  •".'.' 

Field  infirmaries,  treatment  of  wounds  at 146 

Field  surgery 1  .">•> 

Finding  of  balls 182 

Fing0r,  the  proper  probe 117 

Finger,  amputation  of 151 

Fi-lula  in  an 625 

Flannel  shirt*  for  soldiers 21 

Flattening  of  balls 161 

Flour  ration  m  tl-  ai  my 

•   ball     .1-1 


XIV  INDEX. 

bodies  in  brain 

in  irouods 1  IV 

how  found 170 

iii  ^kull 

ronoTa]  of 179 

Forearaii  amputation  of 169 

Food  of  the  soldier 81 

Four-wheel  ambulance  iragon 1 04 

Fracture  of  arm,  treatment  of 

of  teg 107 

gunshot  

Of  rib* 

of  thigh 

of  skull 

French  ambulance  corps ^  ...  1 1  I 

French  loeaos  In  Crimea 1 1 

Frost-bite '•  '■" 

Fumigations  of  hospitals 

•  0. 

<;.iit>  r  for   Boldiers -  '■ 

Gangrene,  hospital 

General  hospitals 64 

discipline  in 71 

Gunshot  fractures 

(tun shot  wounds,  appearance  ol IftJ 

i if  abdomen 

of  bladder ■  •' 

of  cheat 810 

general  treatment  ol 

of  heart  ■"■l  i 

hemorrhage  in 104 

of  head 273 

of  hand 

bi  the  intostinet :>l  I 

of  the   kid  my 

of  the  lung '■!.' 

of  the  neck *■  •  •"."7 

pain  in 185 

progress  of 214 

of  spine 333 

of  Btomaoh 349 

symptom 


INl'l   \  XV 

11. 

Haemostatics 169 

Halt  during  a  march Hi 

1 1. m .) ,  amputation  of 457 

litter 100 

wounds  of 38S 

Hardships,  effects  upon  young  men 8 

Hat  for  soldier 24 

Havclock 25 

Head  wounds 272 

trephining  in 291 

Health  of  recruits 7 

Heart  wounds 311 

Hectic  fever .255 

Hemorrhage,  amputation  for 212 

arrest  of 1 68 

on  the  brain 2S7 

in  gunshot  wounds 1  >\  I 

secondary 2(>."> 

Hip-joint,  resection  of I'.'.MI 

amputation  of 483 

the  method  of  resection  of 195 

Horse-litter 104 

Hospital  attendants 62 

bed-ticket 81 

cleanliness  of 87 

capacity  of 86 

discipline  in 7!i 

diet ;n; 

disinfection  of '.in 

female  nurses  in 93 

gangrene 298 

general fit 

knapsack I  :,(i 

regimental fiO 

stewards,  duties  of 70 

statistics 12 

•  tents BO 

ventilation  of s<» 

Huaierus,  compound  fracture  of 

Humeral  artery,  ligation  of M)5 

Hydrocele*  • : >26 

Hygienic  property  ol  ulotbing 19 

Hygiene,  rob*  "f  in  hofpitalj  " 


Wl  I.M'KN 

I 

Ih,<    artery,  ligation  of 518 

Improvement  of  surgeoni  In  the  army 131 

■  ration  .if  ball*,  danger  of 180 

Infirmary  OOtpi 112 

Infirmariec    in  the  field 139 

field,  surgeon  -  al    110 

Inflammation  of  the  brain 283 

of  ilio  skull 801 

Injuries  to  tlio  ankle-joint |o  > 

to  the  head 288 

to  joints :;?n 

to  knee -joint (OS 

to  skull,  trephining  for ".".'I 

Intestinal  wounds 341 

J. 

Jaw,  resection  of 1^7 

Joint,  injuries  to 870 

stiff 1.1 

K. 

Kidney,  gunshot  wonndi  of 851 

Knapsaok,  hospital 138 

Knee-joint,  disarticulation  of 188 

injuries 105 

n   ootion  of 197 

I. 

I. oli.      in   lo.,|, Hal 86 

M  ] i u tat  loll   ii I I7t> 

OOmpOUnd  fracture  of I"? 

Ligation  of  arteries 198 

■  f  axillary  artery 8 

of  brachial      "      

of  oarotid       "      " 

of  facial  "      ' Oil 

of  femoral        "        ' 515 

of  fibular        "  511 

ol   iliac  "  518 

of  lingual        "  511 

of  radial  "  _ >04 

ibi  1  avian  •■' 

I  i  iperi  r  thyi  10 


INDEX.  XV11 

Ligation  of  tibial  artery 512 

of  ulnar      "     503 

Ligatures  upon  bleeding  vessels 211 

Limbs  contracted  after  gunshot  wounds 432 

Lingual  artery,  ligation  of 511 

Lisfrano'e  amputation  of  foot 471 

Litter-carriers 112 

Litters,  hand 100 

horse 104 

Lock-jaw 257 

Lower  jaw,  resection  of 487 

Lung  wounds 315 

M. 

Malingering Ill 

Marching,  preparation  for 12 

order  in • 18 

Material  of  armies 2 

Matron,  duties  of  in  hospital 77 

Maxillary  bone,  inferior,  resection  of ls7 

superior,         "         "   488 

Mayor's  posterior  wire  splint 1 397 

Medical  outfit  for  a  regiment 128 

staff  of  armies 107 

staff  in  Confederate  army 108 

stall  of  English  army 110  . 

.-la If  of  Prussian  army Ill 

studies  in  the  army l.'!l 

supplies  for  battle-field 1  '■'>'■'> 

Medicated  water  dressing  for  wounds 200 

Messing  in  the  army 40 

Morpbine,  endcrmic   use  of 222 

Mortitieation  of  stump 416 

Mortality  in  armies 11 

N. 

Neck  wounds 307 

Necrosis  of  skull 30 1 

Nervous  shock 1.'>I 

Night  nurses,  duties  of ..■•   7'i 

Norses,  duties  ol  in  general  bospital 71 

O. 

Opium  in  gunshot  wound* 

2 


.Will 

Id  infirmaries 

■  itrance  and  exit  of  balls. 160 

Outfit)  medical)  for  ;i  regiment 128 

lier 28 

P. 

periodical 

I'n in  In  gun  snot  wounds 165 

Painful  stumps 134 

Panniers  f"r  Held  service  186 

■  in  general  hospital 79 

regulations  l"r  in  general  hospital 

Pelvis,  balls  in 

Perforated  wounds  of  skull 

Peroneal  artery,  ligation  of .HI 

Periodic  pains 267 

Pirogoff's  amputation  at  ankle-joint 476 

Phagedenic  ulceration  in  gunshot  \\ ounds 235 

Physiology  of  clothing It; 

ior  tibial  artery,  ligation  of )13 

wire  splint  of  Mayor 

Preparation  of  rations in 

Primary  amputations 

hemorrhage,  arrest  of 164 

Privies,  construction  of  in  the  field ••'. 

Probes,  examination  with NT 

Probing  of  wounds 1 7."> 

Progress  <  t  gunshot  wonnds 214 

Prussian  army,  medioa!  staff  <•!' ill 

duties  of  surgeons  in 1 1  ."> 

I'n  ,  theory  ol    it-  formation. . . .' 248 

Pys  mis 246 

u. 

Radial  artery,  ligation  of KM 

Rations,  preparation  of 10 

in  the  Confederate  army 87 

Recruits 1 

Rooruits,  health  of 7 

Recruiting  servioe Ll 

Rectal  fistula 525 

Regimental  hospitals 60 

Regimen t,  medical  outfit  of l^s 

Regulations  In  general  hospital 7'.' 


INDEX.  xix 

Regulations,  oode  of  in  general  hospital S2 

for  patients  in  general  hospital 84 

Removal  of  foreign  bodies 17? 

Requisitions  by  medical  officers 1-7 

Resection  of  anklo-joint l!,s 

of  clavicle 189 

of  elbow-joint 386 

of  elbow-joint,  operation  for 493 

of  hip-joint 390 

of  hip-joint,  operation  for.  - 195 

of  knee  joint 197 

of  lower  jaw Is" 

statistics  of 877 

of  shoulder-joint 380 

of  shoulder-joint,  operation  for 191 

treatment  of 185 

of  upper  jaw Is s 

of  wrist-joint 

of  wrist,  operation  for I'M 

Ribs,  compound  fracture  of 331 

Round  halls,  the  comparative  effects  of 11  U 

Rupture  of  abdominal  viscera 354 

S. 

Sabre  wounds 213 

Scalp  wounds 2s  I 

Scurvy 35 

lary  hemorrhage •. 2o:> 

■it  of  tli  e  guard,  duties  of  in  hospital 7* 

Is  for  hospitals S3 

Shelter  tents 50 

Shirts  for  Boldiers 21 

Shoe-  for  soldiers 22 

Shoulder  joint,  disarticulation  of 489 

resection,  operation  for 19] 

resection  of 

Shock,   nervous Iflfl 

Sinks,  in  the  Geld i$ 

Skull,  wound-  of,   with  depression 

Skull,  inflammation  of 291 

Skull,  perforating  wounds  of 298 

Sloughing  of  gunshot  wounds 230 

Bmith'i  anterior  splint 397 

Spent-balls,  effects  of 


XX  IM'EX. 

Bpiae  woaodi 

Staff,  medical  of  armies 107 

medical  of  Confederate  army 106 

medical  of  English  army 110 

medical  of  Prussian  army Ill 

Mai  it- lies  of  army  in  Mexican  war '.• 

of  amputation*  in  Confederate  army 861 

oomparatirc  of  amputations 1 12 

of  Ghimboraao  hospital 12 

of  disarticulations .'171 

of  English  and  French  in  the  Crimea 11 

of  hip-joint  resections 

of  joint  injuries 

of  ligatiou  of  arteries 502 

of  resection  of  shoulder-joint '!77 

of  thigh  fractures 

*tiff  joints 1.50 

Stomach,  gunshot  wounds  of 848 

Stumps,   accidents  t .    121 

conical 136 

inert  ideal  ion  in -tl.r> 

1  mill  ful 124 

Subclavian  artery,    ligation  of 507 

Superior  thyroid  artery,  ligation  of ill 

Supply  of  clothing  necessary  to  health 2»> 

Supplies,   medical,  for  battle  field I  •'<:> 

D,  as- ist  ant 68 

in  chief,  duties  ol   in   Im-pital 68 

in  Confederate  army LOS 

of  division,  duties  of  in  hospital 07 

duties  of  in  Prussian  urmy 116 

duties  of  in  oatnp 128 

duties  of  oa  battle-field I  '■'■'■ 

lo  be  lelt   with  the  wounded 164 

at  Bold  infirmaries 148 

morning  call I '-'  I 

Buseeptibilities  of  soldiers 1 

Syme's  Hinpuiation  at   ankle-joint 17  1 

Bymptomt  accompanying  gunshot  wounds 168 

T. 

I  ibli  "i  imputations 861 

oompound  fraotures  of  thigh 395 

disarticulations •'" 


INDEX.  XX! 

Table  of  hip-joint  resections 39.) 

joint  wounds. 872 

ligation  of  arteries 502 

primary  amputations 112 

resections 377 

Tents,  hospital   fill 

improvised 17 

knapsack 50 

shelter 50 

\vnrniin:,'   of I'.) 

Tetanus ?:,: 

Thigh,  amputation  of is  I 

gunshot  fractures  of 395 

Tibial  artery,  ligation  of ,'>1  2 

Ticket  for  hospital  beds St 

Time  necessary  to  make  a  soldier I  It 

Transportation  of  the  sick  and  wounded '. <J',l 

of  wounded  to  hospital 152 

Treatment  of  cerebral  inflammation 285 

of  chest,  wounds 322 

of  compound  fractures 362 

of  concussion  of  brain 275 

of  depressed  fractures 290 

of  face  wounds 30  I 

of  erysipelas 2:^0 

of  frost-bite I.V.I 

of  gunshot  wounds 215 

of  hospital  gangrene 212 

of  periodio  pains 270 

of  pyemia,  preventive 251 

of  ribs,  fractured 880 

of  resections :;7'j 

of  skull,   fractured 284 

of  secondary  hemorrhage 207 

of  tetanus 286 

of  thigh  fractures .',9!i 

Of  wounds H)2 

of  wounds  on  battle-field 114 

of  wounds  at  field  infirmary 148 

Trephining  in  fracture  of  skull -y.n 

mode  of  operating 519 

in  Mexican  war ;t 


xxn  IM ; 

I  . 

Ulnar  artery,  ligation  of 

Pppor  jaw,  roseotion  of Is- 

Utensil  I  rat*   army 

v. 



Ventilation  of  hospitalt 99 



>.  ruptun  "i 

Volunteers i 

W. 

,  ambulance 104 

Ward-master,  duties  of 7.". 

Warming  of  ten U   1'.' 

Water  dressing  for  v.  inndi 199 

Wbiskoj  for  

Wire  splint  for  gunshot  fractures 

Wound  to  Deleft  with l.'i  I 

Is  of  abdomen 

bayonet SIS 

..i  bladder I 

of  obt  -i 

disturbing  inflaenoes  of 

entrance  and  axil  of  balls 169 

examination  of 1 72 

909 

ntof 914 

f 1 57 

of  the  hand 

or  tin-  head 

<>(  the  heart 914 

hemorrhage  in 194 

of  int'   tine 

of  joints 

of  tbi  

ol  the  knee  join) 105 

(>r  the  long 

of  the  b«  ■ 

pain  in 198 

knll 

progrei •  "t ...  .21  I 

probing  of 


TNI'!  XXIII 

Wounds,  sabre ■». . .  .21.'! 

of  the  spine 833 

ui'  tlic  stomach :i !!) 

treatment  of  at  field  infirmary 14fi 

treatment  of  on  battle-field 115 

local  treatment  of I'd' 

Wrist-joint,  resection  of 387 

amputation  of 468 

operation  fur  resection  of. r.i  i 


CHAPTER    I . 

SOSOBPTIBILITIKS  OF  SOLMERS —  MATERIAL  OF  AlSMIES — RECRUITS — 

Conscripts — "Clothing  —  Cleanliness  —  Food  —  Marching  — En- 

CAHPHENTS  —  Amusement's,  etc. 

As  the  strength  of  an. army  depends  more-  upon 
the  health  and  physical  development  of  the  soldier 
than  in  mere  numbers,  the  hygiene  of  camps,  and  the 
susceptibility  of  soldiers  to  disease,  has  long  been  a 
worthy  study  for  military  leaders.  When  men  are 
taken  from  civil  life,  where  they  are  accustomed  to 
think  and  act  for  themselves,  and  arc  gathered  togeth- 
er as.  soldiers,  the  very  act  of  acknowledgment,  or 
mustering  in,  deprives  them  of  all  liberty-,  and  makes 
them  dependent  upon  their  superior  officers.  They 
must  now  live  after  a  formula —  with  its  drills,  labors, 
fatigues,  privations,  exposures,  guard  duties,  night- 
watchings,  long  marches,  and  rigid  discipline.  This 
new  life,  which  is  so  different  from  their  former 
habits,  establishes  a  new  era,  similar  to  acclimation, 
and  which  i>  as  marked  in  its  effects  upon  the  consti- 
tution of  the  soldier. 

Like  acclimation,  this  sudden  change  from  civil  to 
military  Life  constitutes  a  physiological  and  moral 
eri>is,  which  is  evinced  in  an  increased  mortality,  as 
an  initiation,  for  the  first  year  over  succeeding  years 
of  service. 

Tlir  physical  and  organic  revolution  which  this 
change  engenders  establishes  a  special  pathology  for 
soldiers,  which    differs,  in    many    respects,  from    the 


J  MATERIAL    OF    AKMTK- 

regular  forms  which  are  observed  in  tin'  routine  of 
civil  practice. 

The  diseases  of  camps  are  few,  and  exhibit  a  strik- 
ing uniformity  <>f  character,  depondenl  upon  numer- 
ous  depressing  causes,  t<>  which  all  soldiers  are 
equally  liable,  ami  which  belong  in  common  to  every 
army,  irrespective  of  nationality  and  climate.  Con- 
tinued exposure  and  fatigue,  bad  and  insufficient  food, 
>ali  meat,  indifferent  clothing,  want  of  cleanliness, 
poor  shelter,  exposure  at  night  to  sudden  changes  of 
temperature,  infected  tents  and  camps,  form  a  com* 
bination  of  causes  which  explains  the  fatality  of  an 
army  in  the  field. 

Troops  are  u-ually  drawn  from  tin-  rural  districts, 

Where  they  have  never  heen  exposed  to  those  mor- 
bific causes  which  are  incidental  to  tin1  atmosphere  of 

cities,  and   which   entail   a   series   id'  infantile  diseases 

upon  the  growing  generation.  The  unavoidable  ex- 
posure, and  the  general  liability  to  these  causes  while 

in  tran-it,  to  which  city  troops  arc  exempt,  make 
SUCh  diseases  a  fearful  BCOUrge  in  armies.  The 
measles,  a  mild  disease,  which  excites  no  alarm  under 

ordinary  conditions  of  protection  from  the  weather, 

strikes  terror  in  a  camp,  where  it-  Bequeltt,  of  pneu- 
monia and  phthisis,  are  truly  fearful.  This  disease 
alone  has   laid   a   heavy  percent  age  upon    the   effective 

Btrength  of  our  army.  Add  to  this,  ami  kindred 
eruptive  diseases,  glandular  affections,  tuberculosis, 

capillary  bronchitis,  typhoid  and  malarial  fevers,  with 

diarrhoea  and  dysentery,  and  we  have  already  summed 

up  the  chief  causes  of  army  mortality  and  deterio- 
ration of  Strength.  All  of  these  diseases  can,  to  a 
certain  extent,  he  avoided  by  recourse  to  a  proper 
hygiene,  Which  has  not  heen  valued  by  commanding 
officers,    and    in    many    instances    has    neither   been 


MATERIAL    OF    ARMIES.  6 

recognized  nor  urged  by  the  health  officers  of  the 
command.  Until  the  claims  of  hygiene  are  duly 
considered,  and  its  necessity  acknowledged,  the  mor- 
tality will  continue  from  causes  which  can  readily  be 
counteracted. 

After  nearly  three  years  of  bitter  experience,  we 
are  only  now  learning  the  art  of  war;  and  as  men  arc, 
with  us,  the  greatest  desideratum  —  nearly  the  entire 
male  population  of  the  Confederacy  being  in  the  field 
—  officers  arc  beginning  to  feel  the  importance  of  the 
following  maxim:  "Although  the  arms  are  the  fight- 
ing weapons,  the  soldier  is  the  machine  which  wields 
them;"  and  as  there  will  be,  even  in  the  most  active 
campaign,  at  least  an  average  of  twenty  marching 
days  for  one  fighting  day,  if  the  soldier's  welfare, 
health,  and  comfort  have  not  been  carefully  attended 
to  during  the  twenty  days,  his  musket  will  be  of  very 
little  use  to  him  on  the  twenty-first.  It  is  to  him, 
therefore,  that  the  greatest  attention  is  due. 

Prudence  and  forethought  should  be  leading  traits 
in  the  character  of  military  men,  and  are  most  con- 
spicuously exhibited  in  the  carrying  out  of  all  those 
details  so  necessary  in  the  preservation  of  an  efficient, 
force  to  fight  with.  An  army  will  always  be  bur- 
dened  with   heavy   mortuary   lists,  extensive   hospital 

organizations,  a  large  pay-roll,  and  comparatively 
Few  efficient  troops,  unless  officers  take  the  most 
lively  interest  in  the  general  welfare  of  their  men, 
and  cease  t'>  consider  professional  advice  offensive 
and  intrusive. 

As  it  takes  much  time  and  considerable  outlay  to 
make  soldiers,  it  behooves  the  government  to  keep 
them  ina  useful  condition,  which  can  only  be  effected 
by  the  unceasing  labors  of  the  medical  staff,  and  the 
rigid  enforcement  of  all  sanitary  regulations  by  com- 


1  MATERIAL    OF    ARMIES. 

manding  officers.  A  tnong  volunteer  i  roops,  where  the 
regulations  of  r  regular  army  can  not  :it  once  be 
enforced,  it  should  be  the  duty  of  the  officer  In  com- 
mand   t'>   appeal    tf>   the   g I    sense  of  the    Boldier 

through  tlir  orders  of  the  day,  and  gradually  to  instil 
such  wholesome  rules  of  hygiene  as  will  make  them 
individually  careful  for  the  general  good.  The  sick 
list  will  offer  a  fair  criterion  of  the  military  status  of 
an  officer,  and  his  capacity  for  taking  care  of  his  men, 
which  is  one  of  the  first  rules  in  military  science. 

1 ; i «  ri" its. —  Iii  times  of  peace  an  army  is  formed 
of  recruits,  who  are  enlisted  with  much  care.  Bach 
individual,  before  he  is  received,  undergoes  a  critical 
examination  by  the  recruiting  medical  officer,  who 
rejects  all  blemishes,  as  well  as  those  conditions  Bhow- 
inga  predisposition  to  disease;  the  object  gained 
being  the  selection  of  a  body  <•!'  men  who,  from  phy- 
sical and  vital  perfection  <>f  organization,  will  besl 
i  external  morbid  influences. 

Conscripts  and   Volunteers.  —  In  times  of  war, 

especially  he t  ween  contiguous  countries,  win- re  nation- 
al animosity  rages  high,  entire  communities  rush  to 
arms,  ami  with  one  accord  adopl  Camp  life,  with  its 
exposures  and  trials.  This  is  very  conspicuously 
shown  in  the  present  struggle  for  the  independence  of 
the  Confederate  States,  where  tlte  army  absorbs  the 

entire  male   population,  except  such  as   are  physically 

unable  to  be  useful  in  any  arm  of  the  service.  Under 
the  conscript  laws  which  the  Confederate  States  have 
adopted,  the  instructions  to  enrolling  officers  are 
rather  to  prevent  those  within  the  prescribed  ages 
from  escaping  duty,  than  to  select  men  for  their  phy- 
sical  perfection  of  organization.     Every  able-bodied 


MATERIAL   OF   ARMIES.  0 

'man,  between  the  ages  of  eighteen  and  forty- five,  is 
not  only  enrolled,  but  actually  pal  into  the  field. 
These  form  the  movable  army  of  the  republic.  Be- 
side these,  each  state  has  called  out,  to  assist  in  the 
local  defence,  all  such  as  are  capable  of  bearing  arms, 
between  the  ages  oi'  sixteen  and  eighteen,  and  from  for- 
tv-five  to  sixty.  Such,  however,  is  the  determination 
of  our  people  to  establish  their  independence,  and  to 
free  themselves  from  oppression,  that  these  prescribed 
ages  do  not  limit  enlistment;  hut  without  these  limits, 
wherever  there  is  health,  to  enter  the  army  seems  to 
be  the  predominant  passion  —  so  that  many  states  of 
the  Confederacy  present  the  singular  fact,  and  appa- 
rent anomaly,  of  having  in  the  field  a  much  larger 
number  of  men  than  are  represented  by  their  entire 
voting  population.  Entire  districts  have  thus  given 
up  their  health}*  male  population  —  the  only  repre- 
sentatives being  old  decrepid  men,  or  invalid,  maimed, 
and  broken-down  soldiers. 

Among  those  wlio  take  up  arms  in  defence  of  their 
rights,  or  for  the  protection  of  their  homes  and 
families,  are  necessarily  found  men  from  every  por- 
tion in  life  —  from  those  enjoying  the  most  refined 
and  cultivated  social  privileges,  to  the  street  laborer 
—  all  having  a  common  cause  to  support;  men  of 
every  variety  of  constitution,  temperament,  and 
idiosyncrasy;  in  whom  every  form  of  disease  is  found 
larking,  and  ready  to  show  itself  upon  the  slightest 
provocation.  Those  who  have  Led  Lives  of  ease  and 
luxury  are  suddenly  called  upon  to  assist  in  the  stern 
and  laborious  duties  of  the  soldier,  to  share  in  the 
commm  toil,  and  to  bttffel  with  the  elements.  The 
liar  mode  of  living,  and  other  hardships  which 
they  daily  undergo,  to  which  the  majority  arc  to- 
tally unaccustomed,  are  more  injurious  than  the  ex- 


fl  MATERIAL   OF   ARMIE8. 

posures  to  which  they  submit,  and  to  the  sanitary 

influence    of    which    they    owe.   unwittingly,  much    of 

the  health  which  soldiers  enjoy.  Exercise  in  the 
op  'u  air  count  tracts  many  of  the  would  -  he  injurious 
effects  of  exposure j  and  soldiers,  who  have  lived  for 
in. >nth-<  without  tents,  sleeping  under  the  protection 
of  trees,  exposed  to  the  dew-  and  rain^,  find  them- 
selves  suffering  from  colds  and  catarrhal  affections 
only  when  they  are  permitted,  under  furlough,  to 
enjoy  a  lone;  wished -for  visit  to  their  families,  with 
the  now  doubtful  comfort  of  a  close  room  and  BOf! 
l»ed.  The  physical  improvement  is  surprising,  which 
the  gloved  members  of  high  lite  exhibit,  after  even  a 
few  weeks  campaign,  although  followed  under  the 
in  » - 1  disadvantageous  circumstances  of  inclement 
weather. 

This  was  well  shown  among  the  troops  protecting 
the  batt  >ries  in  the  neighborhood  of  Charleston  har- 
bor, prior  i  •  the  taking  of  Fort  Sumter.  When  the 
call  to  arm-  was  made,  the  militia  —  composed,  in  a 
large  maasure,  of  clerks,  merchants,  and  professional 
in. mi.  most  of  whom  were  much  more  familiar  with 
the  duties  of  the  desk  than  manual  labor  —  with  one 
common  Impulse  rushed  to  meet   the  enemy.     Many 

Of    t  hem.  of  delicate  frames,    and    frail    constitutions, 

exposed  themselves  upon  sandy  islands,  directly  upon 
the  Bea- beach,  with  little  or  no  protection.  They 
were   badly    housed,  irregularly   fed,  and   miserably 

watered.      Their    daily    duties    were,    with    pick    and 

shovel,  to  throw  up  redoubts,  establish  batteries,  ami 
mount    heavy  ordnance,  during  the  day;  while  their 

nightB,  when  not  spent  in  anxiously  watching  for  an 
expected  invasion,  or  performing  tedious  guard  duty 
during  a  vty  long  spell  of  stormy  wintry  weather, 
were  forgotten   in  sweol   oblivion   upon  the  wet  sand, 


MATERIAL    OF    ARMIES.  7 

at  times  without  the  shelter  of  a  tent.  Notwith- 
standing such  exposure,  the  sanitary  condition  of  the 
troops  was  excellent;  and  many,  of  delicate  frame, 
returned  to  their  homes,  at  the  expiration  of  two 
months,  sturdy,  robust  men,  with  an  addition,  in 
some  cases,  of  twenty-five  pounds  weight.  All,  with- 
out exception,  were  improved  by  the  change  of  life, 
under  the  exhilarating  influence  of  sea  air  and  active 
exercise. 

It  has  been  often  noticed  that  soldiers,  taken  from 
the  hotter  classes  of  citizens,  go  through  campaigns 
of  great  exposure,  with  many  privations,  much  better 
than  the  heavily- built  yeomanry.  This  can  be  ac- 
counted for  in  the  personal  care  of  the  one,  and  the 
known  carelessness  of  the  other.  For  the  same 
reason,  officers  are  comparatively  exempt  from  thoso 
diseases  which  ordinarily  fill  the  hospitals  with  sick 
from  the  ranks.  The  immunity  from  infantile  dis- 
eases which  the  adult  inhabitants  of  cities  possess,  on 
account  of  attacks  during  childhood,  is  one  of  the 
most  noted  reasons  why  city  troops  suffer  less  in  a 
campaign  than  soldiers  from  the  country. 

All  armies  confirm  the  well-established  fact  that 
raw  recruits,  in  the  field,  always  suffer  more  than 
veterans.  In  the  Crimea,  thousands  of  recruits  filled 
the  hospitals  en  route,  before  arriving  at  the  seat  of 
war.  These  troops  had  been  collected,  indiscrimi- 
nately, under  a  pressure.  Many  of  them  were  youug, 
ill-conditioned,  undeveloped  in  body,  unconfirmed  in 
constitution,  and  hence  without  stamina  or  powers  of 
endurance.  When  compelled  to  undergo  the  hard- 
ships of  a  Biege,  where  the  strength  of  full-grown 
men  soon  failed,  they  were  very  quickly  used  up. 
Unaccustomed  to  either  the  work,  food,  or  exposure 
to  which  they  were  compelled  to  submit,  they  were 


MATERIAL    01    AUMIKs. 

readily  affected  by  diseases —  and,  when  severely  at- 
tacked, they  usually  died ;  or,  it  they  Burvived,  their 
convalescence  was  painfully  prolonged,  and  the  least 
imprudence  produced  a  relapse.  Napoleon,  in  making 
a  demand  for  troops,  asked  for  men,  as  he  well  knew 
that  boys  only  encumbered  the  hospitals  and  road- 
Bides. 

An  English  Crimean  Burgeon,  in  speaking  of  the 
character  <>t  the  troops  Benl  to  the  Bast,  and  oi 
the  hardships  to  which  they  submitted,  mentioned  to 
me  that  premature  old  age,  decrepitude,  with  feeble^ 
bent  frames,  wrinkled  faces,  and  grizzly  locks,  were 
Been  in  youths  of  two  or  three  and  twenty  —  the 
effect  of  two  winters'  toil,  want,  and  misery. 

Our  own  experience  does  not  corroborate  that  of 
European  armies.  The  spirit  anil  chivalry  of  our 
youth — the  result  of  their  education  and  mode  of 
living— -induced  large  numbers  between   the  ag< 

Join-teen    and    eighteen     to    enter    the     army.      These 

have  shared  the  toils,  fatigues,  and  privations  of  our 
troops,  in  one  of  the  most  active  Beries  of  campaigns 
in  the  experience  of  modern  warfare.  So  tar  from 
encumbering  the  hospitals,  they  now  comprise  our 
most  robust  and  best  soldiers,  capable  of  undergoing 
great    fatigue  and  privations    and   equal    to   any   emer- 

ey. 

In  examining  the  statistics  of  the  Mexican  war.  we 
find  the  well -estahlished  rule,  that  volunteers  sutler 
more  than  regulars,  confirmed,  although  the  material 
of  which  the  volunteer  force  was  composed  was  much 

superior  to  the  average  of  armies  from  conscriptions 

Or  forced  enlistments.  The  troops  sent  out  from  the 
states  were  picked  men,  well-developed  in  bodily 
frame  and  constitution;  yet  we  find  a  fearful  disparity, 
when  we  compare  the  mortuary  reports  of  the  three 
different  arms  of  the  service. 


MORTALITY    IN    ARMIES.  5> 

The  three  classes  of  troops  in  the  war  with  Mexico 
were:  the  old  or  standing  army,  composed  of  men  ac- 
customed to  the  fatigues  and  routine  of  a  soldier's 
life;  ten  regiments  Of  enlisted  men,  carefully  selected 
by  recruiting  surgeons  ;  and  73,000  volunteers,  taken 
at  random  from  all  walks  of  life.*  The  total  loss  in 
the  old  arm}',  by  deaths,  discharges,  resignations,  and 
desertions,  exclusive  of  discharges  by  expiration  of 
service,  was  7,033  in  an  aggregate  force  of  15,736 — 
being  50.70  per  cent,  for  the  whole  service  of  twenty- 
six  months,  or  a  monthly  loss  of  1J95  per  cent.  In 
the  ten  new  regiments,  using  the  same  basis,  the  total 
loss  was  3,830  in  an  aggregate  strength  of  11,186 — 
being  34.22  per  cent,  for  the  whole  service  of  fifteen 
months,  or  a  monthly  loss  of  2.28  per  cent.  In  the 
regiments  and  corps  of  volunteers  the  total  loss  was 
20,385  in  an  aggregate  force  of  73,260 — being  27.82  per 
cent,  for  the  average  period  of  service  of  ten  months, 
or  a  monthly  loss  of  2.78  per  cent.  When  it  is  re- 
membered that  tjie  old  army  stood  the  brunt  of  all 
the  early  engagements,  and  that  many  of  the  volun- 
teer regiments  were  never  in  battle,  the  dangers  of 
camp  life  to  volunteers  and  raw  recruits  become  more 
conspicuously  evident.  The  old  army  sustained  a 
loss  of  5.03  per  cent,  from  killed  in  battle  or  dying 
from  wounds — a  loss  of  792  men  from  15,730.  The 
ten  new  regiments  met  with  a  loss  of  143  from  11,186, 
or  1.27  per  cent.  The  volunteer  corps,  numbering 
78,260,  lost  in  buttle  and  from  wounds  only  613,  or 
0.83  per  cent.;  while  the  actual  sick  list,  carefully 
compiled,  and  leaving  out  all  losses  to  the  army  ex- 
cept from  sickness,  amount  to  15,617,  Or  26.83  per 
cent. 

'Medical  Btatiatfca  U.  8.  Army,  1839  to  1854. 


".<•  MORTALITY    IN    A.RMI1 

These  statistics,  collected  with  great  care  by  1 1 » * • 

irgeon-general  of  the  I  * ni t <•<!  States,  portray,  in 

vivid  colors,  the  effect  of  the  exposures  and  hardships 

of  an  active  campaign  upon  those  who,  for  the  first 

time,  adopt  the  life  of  a  soldier. 

Oar  very  extended  experience  in  this  war  for  Con- 
federate Independence  confirms  the  established  rule 
thai  it  takes  time  to  make  a^oldier,  and  that  it 
requires  at  least  t  welve  months  for  a  recruit  t"  exhaust 
tin-  list  of  initiatory  diseases,  and  inure  himself  t«> 
the  privations,  exposures,  ami  labors  of  veterans  of 
tin'  Confederate  army.  This  preparation  does  not 
show  itself  t<>  so  great  an  extent  when  the  army  is 
stationary.  hut  tfll>.  without  fail, under  forced  march- 
esand  hard  fight im:.  with  little  food, and  as  little  rest. 
The  first   year  of  tin-  campaign  the  hospitals  were 

filled    with    the    Bick,   ami    hut    the    skeletons   of  large 

regiments  represented  the  efficient  strength  on  field- 
days.    Now  the  Bick-roil  is  wonderfully  small,  ami  by 

jar  the  majority  of  the  army  vigorously  robust.  The 
liability  to  sickness  i-.  however,  Btrikingly  shown 
among  the  conscripts  whioh  are  being  continually  as- 
signed to  old  regiments  t<>  fill  up  vacancies  No 
reliance  can  be  placed  upon  such  until  the  initiatory 
acclimation  of  several  months,  on  sick-roll  ami  in  bos- 
pital,  ha-  been  passed.  Even  then,  when,  to  all 
appearances,  they  go  through  the  routine  of  camp  duty 
with  the  ease  of  veterans,  a  march  at  once  exhibits 
their  incapacity  for  the  serious  work  of  a  soldier.. 

A-  not   only    the    valuable    live-   of  ci  I  i/.en  -oldiery , 

forming,  morally,  sooially,  ami  pecuniarily,  our  very 
best  people,  should  be  to  the  utmost  protected,  bul  also, 
from  the  enormous  expense  ami  trouble  incurred  by  a 
nation  in   training  ami  in  transporting  an  army  for 

distant   service,  it   is  imperative  that   the    medical  stall' 


MORTALITY    IN    ARMIES.  11 

labor  to  disseminate  among  tbe  troops  thoso  rules  of 
hygiene,  which,  when  considered  in  its  widest  souse, 
are  so  profitable  in  sustaining  an  effective  military 
strength. 

We  have  just  seen  that,  in  our  own  wars,  as  in  all 
that  have  ever  occurred,  an  army  is  rarely  decimated 
by  the  fire  of  an  enemy.  Those  killed  in  battle  are 
but  a  handful,  when  compared  to  the  victims  of  dis- 
ease. In  Mexico,  our  army  of  100.182  men,  in  an 
average  campaign  of  seventeen  months,  exposed  to 
the  continued  fire  of  an  enemy  who  contested  every 
inch  of  ground  from  the  seaboard  to  their  capital, 
making  a  firm  stand  at  every  strategic  point,  from 
which  they  had  to  be  driven  under  a  murderous  fire, 
lost  but  1,549  men  in  battle  and  from  wounds,  all 
told  ;  while  10,986  died  in  Mexico  from  disease,  be- 
sides the  hundreds — I  would  be  well  within  bounds 
should  1  say  thousands  —  who  returned  home  to  die 
among  their  friends  from  the  effects  of  diseases  con- 
tracted in  ramp.  For  some  time  after  the  war,  vol- 
unteers  formed  a  noted  proportion  of  the  inmates  of 
civil  hospitals,  and  the  chronic  diseases  under  which 
they  were  laboring  were  with  great  difficulty  eon- 
trolled. 

In  the  Crimean  service,  the  statistics  collected  by 
Lord  Panmure,  Minister  of  War,  show  the  English  loss 
to  have  been  ll.\~u — of  wliuh  number  3,448  were 
killed  in  bat  tie,  or  died  from  t  he  effects  of  wounds  re- 
ceived. The  French  I"--,  as  reported  to  his  govern- 
ment by  M.  Scribe,  inspector-General  of  the  French 
medical  service  in  the  Crimea,  exhibits  the  frightful 

1088  by  death  of  63,000,  while  the  admissions  into  hos- 
pital numbered  1 1 1,668. 
Tie-  report  from  the  Surgeon-General  of  the  United 

States,    in    giving  a   medical    history    of  their   colossal 


12  MORTALITY    IN    ARM1 

armies  for  the  year  ending  June  30,  1862,  gives  a  gen- 
eral mortality  of  67  per  thousand — of  which  60  per 
thousand  died  of  and    L7  per  thousand  from 

WOUnda  and  injin\ 

The  statistics  of  our  armies  would  be  found  equally 
Btriking  with  those  already  mentioned.  Our  list  of 
killed  and  wounded,  although  very  large,  by  no  means 
equals  our  mortuary  li-t  from  disoa 

the  beginning  of  the  war  found  us  without  an  or- 
ganization, and  a  vfiry  large  number  of  surgeons  taken 
from  civil  practice,  who  required  a  long  and  tedious 
education  before  they  were  prepared  to  make  useful 
and  carefully -collected  reports  no  complete  statisti- 
cal tables,  showing  the  proportionate  losses  by  wounds 
and  diseases  in  our  armies,  have  been  as  yet  com- 
piled. A  bureau  for  collecting  and  collating  the  re- 
ports of  all  medical  officers  lias  recently  been  organ- 
ized,  and.  under   the   active   supervision  of  Surgeon 

rrcl,  with  an  efficient  staff,  we  may  soon  look  for 
valuable  contributions  to  medical  science.  A  refer- 
ence i<>  ill*-  reports  of  Confederate  military  hospitals 
will,  bowevor,  uphold  tin-  constantly- corroborated 
fart,  that  the  missiles  hurled  by  an  enemy  bounti- 
fully supplied  with  all  tin-  improved  ami  perfected 
implements  <>f  modern  warfare,  are  comparatively 
innocent   when   contrasted   with   the  ravages  of  dis- 

Surgeon  Met  'aw.  in  charge  <>\'  ( Ihimborazo  Hospital, 
at  Richmond,  in  compiling  hi<  report  from  Novem- 
ber I.  1861,  to  November  I,  1863,  gives  17,176  ad- 
missions into  his  hospital,  of  which  number  ' > . 7  1 ' ► 
were  from  gunshot  wounds.  There  were3,03l  deaths. 
of  which  877  were  from  the  effects  <>!'  wounds.  Prom 
the  convenient  position  of  Richmond,  with  railroad 
communications  to  the  many  battle-fields  of  Virginia, 


RECRUITING    SERVICE.  13 

and  the  ready  transportation  for  wounded  men.  this 
report  may  be  considered  a  fair  proportion  of  the  Bick 
and  wounded  in  our  armies — which  would  show  at 
least  ten  dying  from  disease  for  every  one  dying  from 
the  effects  of  wounds. 

The  above  statistics  arc  sufficient  to  show  that  the 
efficiency  of  an  army  docs  not  consist  in  its  great 
numbers,  but  in  the  sanitary  condition  of  the  troops. 

The  duties  of  the  medical  staff  are  paramount — as 
the  nation  should  look  to  them,  as  much  as  to  the 
military  leaders,  for  the  successful  termination  of 
a  campaign.  Let  us  now  see  how  this  health,  which 
is  80  valuable  to  an  army,  can  be  preserved. 

Recruiting  Service. — The  first  protection  which 
an  army  has  is  in  the  recruiting  service,  which  is  :i 
thorough  sifting  of  applicants  for  admission.  The 
duty  of  deciding  on  the  efficiency  of  a  recruit  de- 
pends upon  an  examination  made  by  a  recruiting 
officer  and  a  military  surgeon.  The  service  demands 
that  this  examination  be  thorough,  both  in  regard 
to  moral  and  physical  disabilities.  The  regulations, 
therefore,  enjoin  that  —  "In  passing  a  recruit,  the 
medical  officer  is  to  examine  him  stripped,  to  see 
that  he  has  the  free  use  of  all  his  limbs;  that  his 
chest  is  ample;  thai  his  hearing,  vision,  and  speech 
is  perfect;  that  he  has  no  tumors,  ulcerated,  or  ex- 
tensively-cicatrized legs;  no  rupture,  or  chronic  cu- 
taneous affection ;  thai  he  has  Dot  received  any  con- 
tusion or  wound  of  the  head  that  may  impair  his 
faculties;  thai  he  is  nol  a  drunkard,  is  not  subjeel 
to  convulsions,  and  has  n<>  infectious  or  other  dis- 
order that  may  unfit  him  for  military  service."  The 
Burgeon  is  also  required  t<>  certify,  on  honor,  thai  the 
recruil  passed  by  him  "Isfrei   from  all  bodily  d< 


14  RECRUITING    SERVICE. 

and  mental  infirmity,  which  would  in  any  way  dis- 
qualify him  from  performing  the  duties  of  a  soldier;" 
and  should  it  appear  that  the  recruit  was,  at  the 
time  passed,  physically  unfit  to  perform  all  the  du- 
ties for  which  he  was  mustered  into  the  service,  the 
Burgeon  who  recommended  his  acceptance  becomes 
pecuniarily  liable  for  the  pay  of  the  soldier  during 
the  time  which  he  bas  been  attached  t<>  the  army. 
As  the  recruit  must  he  between  the  age  of  eighteen 

and  thirty-five  years,  at  least  five  feet  tour  inches 
in  height,*  and  able --bodied,  we  can  understand  why 
an  army,  selected  by  a  rigid  observance  <>('  the  above 
regulations,  composed  of  healthy,  robust  men.  in  the 

71g0r    of    manhood,    when     brought     under    thorough 

discipline,  is  in  the  hot  condition  to  preserve  a  high 
Btandard  of  health. 

To  show  with  what  stringency  the  laws  on  this 
subject  are  usually  observed,  we  give  the  recruit- 
ing   list    of  the    United    States  Army    lor    1S:">2.      The 

total  number  examined  were  16,064— of  these  13,338 
were   rejected ;  -,-H>   were   alone   received   into  the 

service.      A.mong    the    causes    Of  rejection    are    found 

the  following:  Not  robust,  too  slender,  unsound,  brc* 
ken-down  constitutions,  general  unfitness,  imbecility, 
unsound  mind,  epilepsy,  intemperance  and  bad  habits, 

hernia  and  lax  abdominal  rings,  varicose  veins  and 
varicocele,  hemorrhoids,  syphilis,  gonorrhoea,  loss  of 
teeth,  unequal  length  of  limbs,  general  and  local 
malformation,  contracted  chest,  spinal  curvature,  old 
injuries,  fractures,  etc;  cicatrices,  tumors;  diseases 
of  hones  joints,  skin,  heart,  testis,  and  tunica  vagi- 
nalis; also   of  arms,  eyes,  ears,  glands,  chest,  throat, 

•The  height  of  recruits  required  in  the  French  army,  is  five  feet 
one  inch  :  in  the  United  States  army,  five  feet  four  and  a  half  inches; 
in  the  English  service,  livo  feet  live  and  a  half  inches. 


ENROLLING    SERVICE.  15 

and  abdomen;  detective  hearing,  speech,  and  vision; 
ulcers,  goitre,  ascites  and  anasarca,  obesity,  etc. 

When  we  take  into  consideration  the  little  dis- 
parity of  age  with  the  absence  of  so  many  predis- 
posing causes  of  disease,  we  can  readily  See  why  the 
soldier  by  profession  has  so  great  an  advantage 
over  the  volunteer  force,  into  which  an}-  one  desirous 
of  performing  duty  is  received,  however  unfitted  be 
may  be.  physically,  for  the  toil  and  privations  of 
camp  life. 

Under  the  General  Conscript  act,  now  enforced  in 
the  Confederacy,  the  instructions  to  the  enrolling 
officer  are  to  allow  no  one  capable  of  performing  any 
duty  to  escape,  rather  than  select  men  for  their 
physical  perfection.  The  result  is  that  many,  totally 
unfit  for  military  duty,  are  forced  into  the  ranks,  from 
whicb  they  are  soon  transferred  to  the  hospitals, 
where  they  remain  a  useless  expense  to  the  govern- 
ment— increasing  the  number  without  adding  to  the 
strength  of  our  forces.  In  the  meantime,  the  country 
loses  their  labor  in  the  agricultural  or  mechanical 
occupations  to  which  they  had  been  accustomed,  and 
in  the  pursuit  of  which  they  would  have  been  really 
useful.  Where  an  entire  male  population  is  conscribed 
and  enrolled  for  active  service  in  the  field,  it  Increases 
greatly  the  expenses  without  adding  to  the  effec- 
tive Btrength  of  the  army.  The  same  precautions, 
with  critical  examination  into  the  physical  condi- 
tion of  conscripts,  should  be  made  as  ordered  in  the 
enlistment  of  soldiers;  and  stub  as  surgical  experi- 
ence foresees  will  be  the  constant  inmates  of  mili- 
tary hospitals,  should  be  permitted  to  aid  the  gov- 
ernment in  a  civil  capacity,  by  preparing  those  ar- 
ticles of  prime  necessity  upon  which  an  army  can 
be  alone  supported. 


L6  CLOTHING    OF   TROOPS. 

To    OBTAIN    THK     OTMOST    CAPACITY    OF    LARoR    FROM 
Ml  n.     IHKV     MUST     BE     PROPERLY    CLOTHED    AND     WELL 

11. d — Those  are  the  prerequisites,  withoul  which 
their  powers  of  resistance  to  exposure  and  « 
sive  exertion  are  not  developed.  A  soldier  is  com- 
pelled to  familiarize  himself  with  many  occurrences 
which  experience  in  actual  war  shows  to  be  common, 
often  called  upon  for  Laborious  work,  t<>  expose 
himself  t<>  wind  and  rain,  heat  and  cold,  to  snffer  hun- 
ger and  fatigue,  to  travel  at  eight  as  well  as  during 

the  day,  to  sleep  dressed  and  accoutred  in  cloak  or 
blanket.  He  must  be  taught,  when  thus  exposed,  to 
secure  bis  person  from  disease,  and  to  ward  nil'  in- 
jurious consequences.  In  short,  he  oughl  t<>  be  put 
in  possession  of  the  besl  remedies  for  every  contin- 
gency which  may  possibly  happen  in  military  servko. 
This  i>  particularly  the  case  with  an  armed  body 
which    may   he  called    upon    at    any    moment    to  exert 

great   efforts  in   making  forced  marches,  and.  under 

many  privations,  to  meet  a  hold  and  determined 
enemy,  ami  to  repulse  a  superior  force.  The  strength 
m  ,//<  army  is  calculated  rather  by  the  physique  of  its 
men  than  by  numbers,  as  experience  shows  that,  other 
things  being  "/</.//.  men  who  have  been  well  taken  care 
nf  are  capable  of  opposing  successfully  double  (If  force 
badly  provide  d. 

To      PRESERVE      HEALTH      AND     EFFICIENCY,    TROOPS 

must  i:k  well  clothed. — This  is  one  of  the  weighty 
questions  in  the  economy   of  an   army,  and    has    been 
the  Bubject  of  much  study  and  experiment    by  mili- 
tary leaders. 
♦The  object  of  clothing  is  to  protect  the  skin  from 

•  Levy   on  Hygiene,  ls->-v     Jaokson   on    the    Formation,   Discipline, 
and  1  Irmies. 


PHYSIOLOGICAL    EFFECTS    OF    CLOTHING.  17 

diurnal  variations  or  annual  perturbations  of  tho  at- 
mosphere, while  it  absorbs  excretions,  and  thus  be- 
comes the  means  which  allows  man  to  enlargo  his 
native  sphere,  and  successfully  resist  extremes  of  tem- 
perature in  tho  torrid  or  frigid  zones.  The  caloric 
properties  of  clothing  must  be  considered  under  the 
triple  relation  of  absorption,  reflection,  and  conduc- 
tion. Every  body,  whatever  be  its  temperature,  is 
continually  throwing  off  heal  from  every  portion  of  its 
surface,  the  amount  of  radiation  depending  upon  its 
temperature  and  extent  of  surface.  Tho  human  body, 
having  a  superior  temperature  to  that  of  tho  surround- 
ing atmosphere,  reflects  heat  to  such  a  degree  as 
would  be  incompatible  with  life,  were  it  not  con- 
trolled, to  a  great  extent,  by  the  non- conduction  of 
living  tissue,  and  the  protective  influence  of  clothing. 
The  first  retards  the  transmission  of  heat  from  the 
centre  of  the  body,  while  the  second  acts  as  a  screen. 

If  two  bodies,  unequally  heated,  bo  placed  in  prox- 
imity to  each  other,  there  exists  a  tendency  to  pro- 
duce an  equilibrium  of  temperature.  A  third  body 
interposed  would  intercept  entirely  the  heat  until  it 
be  also  heated,  so  that  it  may  emit  from  the  side 
corresponding  to  the  cold  bod}-  that  which  it  absorbs 
from  the  warm  body.  Clothing,  placed  between  man 
and  the  atmosphere,  exercises  this  protective  influ- 
ence in  proportion  to  its  power  of  reflection  and  con- 
duction ;  and  as  clothing  is  a  bad  conductor  of  heat,  the 
outer  surface  of  the  dress  seldom  acquires  tho  tempera- 
ture of  the  person  which  it  covers.  The  incarceration 
of  a  layer  of  air  between  the  person  and  the  clothing, 
and  also  that  which  enters  into  the  meshes  of  tho 
cloth,  still  further  retards  the  transmission  of  caloric — 
heat  passing  to  and  through  the  clothing  very  slowly, 
and  the  layer  of  incarcerated  air  being  a  very  poor 

B 


18  PHYSIOLOGICAL    BFFFCT8    OF   CLOTHINO. 

conductor.  On  a -quiet,  cold  day,  when  we  are  Bur- 
roanded  by  a  little  atmosphere  of  our  own  warming, 
we  feel  much  more  comfortable  than  when  this  non- 
conducting layer  is  constantly  displaced,  as  on  a  windy 
day,  when,  although  the  thermometer  indicates  a 
much  higher  temperature,  the  cold  ia  Bevorely  felt. 

It   is   the  action   of  thee  -    which  explains 

why  the  exterior  of  the  clothing  of  a  Boldior,  bivou- 
acked without  shelter  under  the  clear  sky,  is  colder 
than  the  surrounding  air.  As  bad  conductors,  the 
heal  whioh  escapee  from  the  skin  traverses  slowly  the 

thickness  of  clothing ;  hut.  a-  a i  as  it  reaches  the 

external  surface,  it  is  radiated  or  emitted  rapidly. 
The   protection  of  a  tent,  or  even   a   cloak,  countor- 

bs  this  radiation.  The  inverse  protection  whioh 
the  blanket  gives  the  Spaniard  or  A  rah  in  hot  weath- 
er, is  similarly  accounted  for.     The  radiating  proper- 

a  of  wool  exceed  its  conducting  or  absorbing  pow- 
and  throw  ofl  the  great   heat  of  the  sun  before 

it  can    penetrate    the  thickness  of  clothing   and    reach 

the  w  ,  arer's  skin. 

Besides  the   property    just    enumerated,    the   hy- 

metric    powers    of   different    fabrics,   condensing 

moisture    from     the    air    and    absorbing     pe^spira- 

.    are    of    much     importance     in    the    Banitary 

>nomy  of  clothing.  In  either  case,  their  power 
of  conducting  heat  is  increased;  and,  therefore, 
the  more  moisture  they  oontain  in  their  meshes, 
the  colder  they  are  as  apparel.  The  Mind  which 
the  doth  imbibes  takes  the  place  ,,i  air,  and  be- 
comes a  cause  of  refrigeration  by  evaporation, 
robbing  the  neighboring  skin  of  its  heat  to  form 
aqueous  vapor.  Linen,  for  instance,  imbibes  at 
once  moisture  from  any  source,  and  chills  the 
body     by    the    evaporation    of  this    moisture;    tins 


PHYSIOLOGICAL    EFFECTS   OF   CLOTHING.  19 

material  for  articles  of  clothing  exposes  the  body 
to  sensations  of  cold  and  dampness,  and  necessa- 
rily to  the  diseases  which  are  brought  on  by 
such  exposure.  Cotton  fabrics,  although  not  so  at- 
tractive to  moisture,  permit  absorption  and  evapora- 
tion to  a  considerable  extent;  while  woollen  goods 
condense  moist  are  as  badly  as  they  conduct  heat; 
from  them  evaporation  goes  on  so  very  gradually  as 
scarcely  to  chill  the  external  surface  of  the  clothing. 

The  hygrometric  properties  of  clothing  are  in- 
timately connected  with  their  action  upon  the 
skin,  when  considered  as  an  organ  of  absorption 
and  excretion.  Cutaneous  perspiration  varies  in 
quantity,  according  to  the  powers  of  conduction, 
radiation,  and  heat  -  absorbing  properties  of  cloth- 
ing, which  can  not  modify  the  exhalation,  al>- 
BOrption,  and  sensibility  of  the  skin,  without 
reacting  upon  its  functions.  The  energy  of  cuta- 
neous elimination  regulates,  in  a  measure,  the  march 
of  other  excretions.  Anything  which  impresses  the 
nerves  of  the  skin  excites  equally  the  origin  of  these 
nerves,  and  causes  exaltation  or  depression  of  the 
system.  Clothing  determines  the  antagonism  which 
existB  between  animal  heat  and  external  temperature. 
Tin'  source  Of  animal  heat  increases  or  diminishes 
it-  activity  according  to  changes  in  the  atmosphere; 
but  the  unequal  production  of  heat  causes  corre- 
sponding oscillations,  in  the  movements  of  respiration 
and  circulation,  in  the  action  of  the  muscles,  and  the 
brain.  Clothing  affects,  then,  all  the  functions  of 
the  economy,  and  may  clearly  represent  the  question 
Of  health. 

A-  the  objeel  of  clothing  is  usefulness  and  conve- 
nience, the  best  uniform  is  that  which  will  protect  the 
body  from  the  inclemencies  of  the  weather,  and  which 


■It    TROOPS 


mpedes  the  movements  whioh  are  connected  with 
military  duties.  Experience  in  the  Held  teaches  what 
can  l>c  dispensed  with,  <>r  what  can  be  added  with  ad- 
vantage.  The  clothing  selected  depends  much  upon 
the  habits  ofa  people,  and  the  country  in  which  the  wal- 
ls carried  <m.  We  can  readily  understand  how  absurd 
it  would  be  in  the  English  government  Bending  their 
home  troops,  in  their  thick  red  coats,  leathered  necks, 
and  shakoed  heads,  to  <1<>  field  duty  on  the  Bcorching 
plains  of  India.  There  arc  certain  portions  <>t'  the 
clothing  which  experience  shows  arc  conducive  to 
health,  in  all  countries,  and  under  every  circumstance. 

The  clothing  for  troops  should  be  made  of  wool,  whether 
the  material  /><  heavy  or  light,  to  suit  the  climate. 

This  rule  should  be  particularly  observed  in  the 
( !on federate  Bervioe,  where,  during  an  active  campaign, 
the  army  being  constantly  in  motion,  the  large  portion 
of  our  troops  bivouac  for  weeks,  or  even  months,  hav- 
ing no  other  Bhelter  than  such  as  can  be  improvised 
from  the  bark  and  branches  of  trees.     Heavy  woollen 

Clothing  alone   can    protect    them    from   disease    whilst 

sleeping  on  the  wet  ground  which  forms  their  nightly 

Collch. 

The  soldier's  coat  should  be  a  frock,  fitting  loosely, 
easy  over  the  shoulders,  with  full  play  for  the  arms, 
without  binding  in  any  way,  and  wide  in  the  body,  bo 
as  not  to  impede  the  expansion  of  the  chest  when 
closely  buttoned.  I  n  the  I  'out  die  rate  service  the  jack- 
et is  now  in  very  general  use,  and  is  preferred  by  our 
troops  for  its  greater  convenience  in  the  performance 
of  the  drill,  and  in  marching.  Besides,  from  the  con* 
Btanl  bivouacking  of our  army  and  the  Bleeping  of  our 
men  around  fires,  the  tails  of  the  coat  are  so  frequently 
burnt  off,  to  the  detriment  of  the  suit  of  clothing,  that 
they  have,  on  this  account,  been  to  a  great  extent  dis- 


CLOTHING    FOR    TROOrS.  21 

carded.  The  trousers  should  be  of  good,  heavy  woollen 
material,  made  also  free  for  the  easy  play  of  the  limbs. 
When  the  bottoms  are  faced  with  leather  or  enamelled^ 
cloth,  it  is  found  a  great  protection  in  had  weather, 
and  also  from  the  dews,  keeping  the  legs  dry  and 
warm.  Flannel  shirts,  coming  well  down  upon  the 
thighs,  and  drawers  of  the  same  material,  are  of  great 
hygienic  utility,  and  should  farm  a  portion  ofthedress 
of  every  soldier,  whether  he  has  been  accustomed  to 
wear  flannel  or  not.  In  winter  the}T  retain  the  animal 
heat  and  support  the  healthy  function  of  the  skin, 
while  in  summer  they  absorb  more  readily  the  excess 
of  perspiration  which  occurs  under  severe  exercise. 
While  agreeable  to  the  wearer,  they  prevent  sudden 
arrests  of  perspiration,  and  are  thus  a  protection 
against  diarrhoea  and  dysentery,  which  are  so  fatal  to 
armies.  These  should  be  furnished  in  sufficient  num- 
bers to  enable  the  soldier  to  change  his  shirt  when  he 
has  been  exposed  to  rain,  as  he  may  thus  prevent 
pneumonia  and  bronchial  affections. 

In  the  French  service,  where  flannel  underclothing 
is  not  in  such  constant  use  as  in  the  English  and 
American  service,  every  soldier  carries  a  band  of  flan- 
nel, with  which  he  envelopes  his  abdomen,  as  a  safe- 
guard from  abdominal  affections,  Baudens,  one  of  the 
surgeons-in-chief  of  the  Crimean  service,  speaks  of  this 
hand  as  essential  to  the  health  of  the  troops,  and,  at 
the  same  time,  refers  to  the  much  better  and  more 
convenient  protection  which  the  English  flannel  shirt 
gives  to  the  men.  The  liability  of  Losing  the  flannel 
girdle,  and  its  very  partial  protection,  is  a  serious  ob- 
jection to  its  use.  For  similar  reasons,  heavy  socks 
should  always  lie  given  to  soldiers,  as  they  retain 
warmth  to  the  feet — which,  being  at  the  greatest  'lis- 
tance    from   the   centre   of  the   circulation,    are    leas! 


22  CLOTHING    FOB    TROOP8. 

capable  of  resisting  cold,  and  therefore  require  n  1  * »— t 
protect  ion  against  injury. 

1  'in-  feel  mi-.'  part  of  the  person  of  a  soldier  bo  essen- 
tial for  the  performance  of  military  doty,  thai  their 
condition  should  be  particularly  attended  to  by  the 
officers.     77m  r  half-boots  should  be  well 

made,  of  good,  durable  material,  and  well  fitted  t<>  the 
.  \  to  1  be  wearer.     The  solos  Bhould 
I"-  broad,  thick,  and  firm,  high -quarter*  d,  bo  as  I 
dude   mud   or  sand,  and  closely  fitting  around  the 
instep,  bo  that  tenacious  clay  can  n«>t  easily  drag  it  from 
>t.     A  good  shoe  or  bool  aiMs  often  as  much  t<> 
the  efficiency  of  the  Boldieras  a  good  weapon.     BCaroh- 
ing  is  as  necessary  a  quality  as  fighting,  and  is  made 
;  the  requisites  in  becoming  a  memberofthe  Im- 
perial Guard  of  the  present   French  emperor.     When 
the  ahoes  <l"  aot  tit  the  wearer  who  is  compelled  to 
use  them.  Bore  i"«»t .  a  very  troublesome  complaint  in 

the  army,  is  brought  On.      From  thi->  cause,  men  (iii  the 

march  are  found  lagging  behind  from  lameness,  and 

are  exposed  t"  be  out  off  by  marauding  parties  of  the 

enemy.  The  leather  should  he  well  smeared  with 
.  oil,  wax,  tallow,  or  other  composition,  to  make 
them  water-proof,  soft,  and  more  durable.  This  should 
he  done  daily  in  wet  weather.  One  pound  of  tallow 
ami  hair  a  pound  of  rosin  melted  together,  and  applied 
hot  with  a  painter's  hrush,  and  renewed  until  neither 

sole  nor  upper  leather  will  take  up  any  more,  18  found 

an  admirable  leather  preservative.     The  grease  alone 

WOUld,   in    time,    rot    the    leather,    hut    the    addition    of 

rosin  gives  the  compound  antiseptic  properties. 
Iii  the  Crimean  service  the   Russian  half- hoot  was 

found  BO  Superior  an  article  over  the  boots  or  shoes  of 
the  Allies,  that  they  were  soughl  for  with  avidity  upon 
the   dead,  as   soon    as   they  were  shot   down,  and  were 


CLOTHING    OF    SOLDIERS.  23 

more  prized  than  any  otfier  article  of  wearing  apparel, 

so  conducive  were  they  to  t  lie  comfort  of  the  wearer. 
They  protected  the  feet  perfectly  from  the  mud  in 
which  the  troops  lived  for  months.  Our  government 
found  so  much  difficulty  i"  furnishing  a  sufficient 
amount  of  shoes,  that  our  troops  were  often  barefooted, 
going  into  battle  over  frozen  ground  without  shoes, 
and  after  a  victory  supplying  their  wants  from  the 
Federal  dead.  After  every  battle,  when  the  burial 
parties  are  ordered  to  their  work,  the  shoes  of  the  slain 
will  have  already  disappeared.  It  was  only  bj'  a 
general  appropriation  of  clothing  found  on  battle-fields, 
that  many  of  our  soldiers  were  made  comfortable. 

The  French  gaiter  used  in  the  Crimea  was  made  of 
heavy  Avhite  cloth,  covering  two-thirds  of  the  foot,  and 
extending  some  distance  up  the  leg.  usually  over  the 
knee.  It  facilitates  walking,  and  prevents  enlarge- 
ment of  the  veins,  while  it  protects  the  limb  from  cold 
and  wet.  Experience  in  the  field  and  upon  the  march 
has  proved  them  so  serviceable,  that  the  entire  French 
army  is  provided  with  them.  The}',  as  a  substitute 
for  the  boot,  might  be  added  with  advantage  to  the 
equipment  of  the  soldier.  When  made  of  leather,  they 
become  hard  after  getting  wet,  and,  by  pressure,  exco- 
riate the  ankles.  Beside  which,  the  leal  her  is  cold  in 
winter  and  very  hot  in  summer.  The  only  advantage 
in  the  leather  gaiter  is  durability  ;  the  cloth  wears  out 
much  sooner,  and  also  becomes  saturated  with  moisture 
in  very  wet  weather.  In  addition  to  the  gaiter,  many 
of  the  French  troops  wear  greaves,  made  of  heavy 
patent  leather,  which  cover  the  leg  to  the  knee,  shut- 
ting in  the  bottom  of  the  pants.  This  gives  them 
.t  facilities  in  walking,  as  it  protects  the  leg  of  the 
pantaloon   from  becoming  foul  with   mud.  which   is  an 

endless  annoyance  to  troops  marching  in  bad  weather 

Every  soldier  should  have  an  overcoat  of  stout  cloth 


24  CLOTHING    OF    SOLDIERS. 

reaching  below  his  knees,  with  a  cap  -ingthe 

This,  like  all  other   a  of  clothing, 

mid  bo  mil-  easy,  to  permit  of  every  movement 
without  binding.  The  French  have  added  a  hood,  to 
pr  ■■  ;  the  hea  1  and  neok  in  ba  I  weather  from  cold, 
win  1.  and  ruin,  whieh  is  a  great  protection,  diminish* 
ing  the  frequency  of  catarrhal  affections.  When  on 
guard  duty  in  bad  weather,  the  hood  is  a  great  comfort, 
and  it  is  also  of  groat  utility  in  protecting  the  bead 
and  neck  from  the  damp  ground  when  sleeping.  Cri- 
mean soldiers  found  i  his  addition  a  great  improvement. 

In  selecting  a  color  for  a  uniform,  it  should  he 
remembered  that  light  colors  absorb  less  than  dark: 
and,  also,  that  odoriferous  exhalations  adhere  with 
much  greater  pertinacity  to  dark  than  to  Light 
clothing,  which  ifl  an  item  of  no  small  importance, 
when  the  deleterious  emanations  accompanying  large 
bodies  of  men  are  oonsi  lere  I.  Beside  whieh.  ex- 
perience in  battle  Bhows  that  certain  colors  make 
much  bettor  marks  to  fire  at  than  others;  and.  ac- 
cording to  calculations,  a  soldier  dressod  in  light  cloth 
is  much  less  liable  to  be  hit  than  in  dark.  The 
following  percentage  is  said  to  be  the  relative  lia- 
bility :  red,  twelve;  rifle-green,  seven;  lu-own,  six; 
Austrian  bluish -gray,  five.  Red,  which  is  the  most 
attractive  and  fatal  color,  is  more  than  twice  as  much 
so  ;is  gray,  which  is  the  least. 

The  best  military  h<it  in  use  is  a  li.^ht,  soft  fell, 
with  a  sufficiently  high  crown  to  allow  space  for  air 
over  the  brain.     The  rim  can  be  fastened  up  in  fair 

weather;  and,  when  turned  down,  protects,  in  a 
measure,  from  the  rain  or  from  the  rays  of  the  sun. 
In  a  warm  climate,  the  light  color  of  the  hat  adds 
much  to  the  comfort  of  the  wearer.  The  small. 
French,  jauntily-fitting  kepi  is  light,  but  does  not 
protect  the   face;  and,  when   made  of  dark  materials, 


CLOTHING    OF    SOLDIERS. 


25 


concentrates  the  solar  rays  upon  the  head.  This, 
however,  can  be  in  a  measure  obviated  by  adding 
a  llavelock,  which  consists  of  a  cap-cover  with  a  long 
cape  attached,  hanging  down  upon  the  shoulders, 
which  protects  the  neck  from  the  sun  in  the  day,  and 
draughts  at  night.  It  is  made  of  light  cloth,  of  a 
light  color,  for  reflecting  heat.  Those  who  have  -worn 
them  on  a  march,  or  when  exposed  to  the  sun's  rays, 
speak  in  extravagant  terms  of  the  comfort  and. 
protection  which  they  give.  The  advantage  of 
wearing  a  light  and  high-crowned  hat  is  that,  under 
exposure  to  the  sun,  as  during  a  march,  a  small,  wet 
handkerchief  placed  in  the  crown  will  not  onty  pre- 
vent sunstroke,  but  will  add  much  to  the  comfort  of 
the  soldier. 

According  to  the  army  regulations  of  the  Confedei*- 
ate  service  a  soldier  is  allowed  the  uniform  and 
clothing  stated  in  tho  following  table,  or  articles 
thereof  of  equal  value  : 


CLOTIIINT.. 


Cap,  complete 

Cap-cover 

Coat 

Trousers 

Flannel  shirt 

Flannel  drawers 

Bootees,*  pairs x. . . 

Stockings f 

r  stock 

<  I  rent -ma: 

Stable  frock  (for  mounted  men) 

Fatigue  overall  (for  engineer!  and  ordnance) 
Blanket 


FOR   THREE   TEARS. 

1st. 

2 

I 

O 

3 
3 

3 
4 

1 

1 

1 
1 
1 

2d. 

1 
1 
1 
2 
3 
2 
4 

..: . 

3d. 

1 

1 
1 

a 

:i 
2 
4 

i 

i 
i 

Total 

for 

threo 

year*. 


I 

3 
1 
7 
9 
7 
12 
12 
1 
1 
1 
S 


•  •Mounted   men   may   rcceivo   one  pair  of  "boots  "nnd  pro  pair   of 
"booteos,"  instead  of/our  pair  of  booteoe. 

0 


CLOTHING    OF    BOLDIEES 

In  the  field,  there  should  be  always  a  supply  of 
clothing  at  band,  to  replace  the  loss  by  unavoidable 
accident  During  the  Crimean  service,  Dr.  BicLeod 
informs  us  that  the  deficiency  of  clothing,  which  was 
so  much  oomplained  of,  was  one  of  the  mosl  prolific 
sources  of  subsequent  dieeaae  among  the  English 
troops.  The  truth  of  this  statement  was  corroborated 
by  our  experience  in  the  campaigns  of  1861  and  1vol'. 
where  a  greal  amount  of  sickness  could  be  traced 
to  insufficient  clothing. 

liers  arc  expected  to  have  always  an  extra 
suit  of  underclothing,  and  usually  have  an  extra  pair 
of  pants  and  shoes.  It.  :it  the  weekly  inspections, 
their  clothing  is  found  deficient,  it  is  the  duty  of  the 
to  report  such  instances  to  company  offi- 
oers,  who  are  instructed  to  draw  from  the  quarter- 
master Buoh  articles  as  are  necessary  for  the  cWnfort 
of  their  men.  Should  they  have  already  drawn  all 
the  clothing  which  army  regulations  allow,  the  value 
of  such  extra  clothing  will  be  deducted  from  their 
monthly  pay.  This  regulation,  when  attended  to 
prior  to  a  march,  insures  a  chango  of  clothing,  which 
isential  to  cleanliness  and  comfort. 

One  of  the  universally  admitted  maxims  for  pre- 
serving health  in  a  campaign,  irrespective  of  climate 
or  locality,  is,  that  soldiers  must    protect  themselv 
summer  from  night  air  by  warm  clothing. 

A    heavy  blanket,  not  in  name  but   in  weight,  and 

one  and  a   half  yards    of  india-rubber  cloth,  complete 

quipment  of  a  soldier.     The  india-rubber  cloth  is 

a  water-proof  covering  for  him  during  exposure,  and 

will   always   make  tor  him   a  dry   bed,  upon  which  he 
can  find  health  as  well  as  comfort. 

We  make  the  following  extract,  on  the  extent  of 
a  soldier's  equipment,  from  Jackson's  Formation,  Dis- 


CLOTHING    OF   SOLDIERS.  27 

ciplinc,  and  Economy  of  Armies,  hi  the  form  and 
fashion  of  a  soldier's  equipment,  "The  adjustment  of 
the  kind  and  quantity  of  articles  termed  necessaries  is 
a  matter  of  importance,  and  as  such  requires  to  be 
well  considered.  It  is  demonstrably  proved,  to  the 
conviction  of  all  persons  who  have  served  with  armies, 
that  superfluous  baggage — that  is,  baggage  beyond 
the  narrowest  measure  of  utility — instead  of  bringing 
comfort  to  the  possessor,  is  a  cause  of  great  annoy- 
ance and  vexation.  A  complete  change  of  the  smaller 
parts  of  dress,  in  the  event  of  being  wet  with  rain, 
together  with  a  cloak  as  a  covering  for  the  night, 
is  all  that  a  soldier  requires  for  his  comfort  and  the 
preservation  of  his  health;  and,  as  such,  it  is  all  that 
he  ought  to  he  permitted  to  possess.  Where  persons 
have  not  more  than  one  change  of  raiment,  the  strong 
impression  of  necessity  obliges  them  to  prepare  for  the 
return  of  want.  Where  there  is  a  superfluity,  the 
necessity  does  not  present  itself  so  forcibly,  and  hence 
the  dirty  clothes  are  crammed  into  the  knapsack, 
where  they  accumulate  in  quantity,  without  obliging 
the  individual  to  recollect  that  they  are  not  fit  for 
066  until  they  are  washed.  It  thus  often  happens 
that  a  soldier  who  has  four  or  more  shirts  in  his 
possession,  has  not  one  fit  for  use — while  a  soldier 
who  possesses  no  more  than  two,  has  generally  ono 
in  his  knapsack  ready  for  the  contingent  occasion." 

The  following  is  considered  to  be  a  full  equipment 
for  a  soldier  on  service,  namely  :  two  flannel  shirts; 
two  pair  of  heavy  socks  ;  two  pair  of  flannel  drawers  J 
two  pair  of  shoes,  or  one  pair  of  shoes  and  one  of  half- 
boots;  one  pair  of  gaiters;  a  small  case  of  needles, 
thread,  and  buttons,  for  mending  clothes;  one  small 
shoe-brush,  with  blacking;  combs  and  hair-brush; 
tooth-brush;  one  pice  of  a  iap;  a  sponge  for  washing 


2S  CLEANLINESS    NECESSARY    FOR    HEALTH 

the  body,  and  a  towel  for  drying  it;  two  pocket 
handkerchiefs;  an  overcoat  of  heavy  material,  besides 
hi-  uniform.  He  Bhould  also  have  a  heavy  blanket  — 
r  it"  lined  with  stout  osnaburgs,  to  increase  its 
durability  and  warmth  —  and  two  yards  oi  india- 
rubber  <  1  < » 1 1 1  to  protecl  him  from  the  weather.  He 
should  also  carry  a  knife,  fork,  and  spoon,  a  <a n t .-i-n 
for  water,  and  a  haversack  for  carrying  dressed  pro- 
visions. It'  those  articles  of  clothing  not  in  use  be 
put  up  in  a  neat  and  compact  manner,  and  enveloped 
ill  oiled  cloth  so  as  to  be  secure  from  wet,  and  do- 
posited  in  the  knapsack  for  easy  carriage,  the  soldier 
will  not  be  incommoded  by  their  bulk  or  encumbered 
by  their  weight;  and,  possessing  within  himself  every- 
thing actually  necessary  for  us,',  will  be  independent 
of  the  delay-  and  accidents  so  common  to  the  bag- 
gage-wagons. 

In  the  above  lis!  we  have  purposely  omitted  shav- 
ing apparatus,  as  every  soldier  in  the  field  Bhould 
allow  his  beard  to  grow.  It  protects  his  throat,  and 
often  prevents  lung  diseases,  catarrhal  affections,  etc 
A  heavy  moustache  is  known  to  protect  the  wearer, 

to  a  certain   extent,   from    malarial    influences,  acting 

as  a  sieve  to  the  lungs.     It  also  purifies  from  dust  the 

atmosphere  inhaled  during  marches,  and  thereby  pre- 
vents many  troublesome  diseases.  Cleanliness  die* 
tates  that  the  hair  be  cut  closo  to  the  head,  and, 
although  the  beard  be  allowed  to  grow,  it  should  also 
be  kept  within  bounds. 

Cleanliness. —  Nothing  contributes  more  to  preserve 
health  than  porsonal  cleanliness;  and  a->  the  i'v<-^  use 

Of    soap    LS    a    prophylactic    as    well    as    a   civilizer,  it 

should  he  regularly  distributed  to  the  men.  Daily 
ablutions  should  never  be  omitted;  and,  if  possible, 

the  chest    and  arms,  as  well    as   tho  face  and    neck, 


CLEANLINESS    NECESSARY    FOR    HEALTH.  29 

should  be  well  sponged.  Baths  should  be  used  when- 
ever opportunity  permits.  Whenever  our  troops  en- 
camp near  a  stream,  it  is  now  the  practice  of  careful 
officers  to  have  the  men  marched  down  by  company 
to  bathe,  and  this  is  repeated  as  often  as  cleanliness 
requires.  Keeping  the  shin  clean  prevents  fevers  and 
bowel  complaints  in  warm  climates.  The  largo  expe- 
rience of  our  various  campaigns  only  confirm  the. fact 
that  the  most  cleanly  are  always  the  most  healthy. 
Baudens,  in  insisting  upon  cleanliness,  says,  "That  the 
contrast  in  the  sickness  and  mortality  of  the  English 
and  French  camp  in  the  Crimea  can  be,  in  a  measure, 
attributed  to  the  frequent  ablutions  of  the  English, 
who  washed  their  clothes  in  hot  water,  and  changed 
.their  underclothes  twice  a  week.  It  is  easy  to  under- 
stand how  carelessness  in  this  respect  will  impair  the 
functions  of  the  skin,  and  induce  disease.  At  review 
our  French  soldiers  show  new  clothes,  and,  on  the 
whole,  an  unquestionable  military  equipment,  yet 
these  beautiful  battalions  leave  in  their  passage  a 
strong  smell  of  barracks  not  to  be  mistaken." 

Not  only  the  tents,  but  the  persons  of  soldiers  as 
well  as  their  clothing,  should  be  daily  inspected. 
However  particular  men  ma}"  be  in  civil  life,  as  soon 
as  they  are  put  into  tho  field  not  only  are  all  habits  of 
cleanliness  neglected,  which  we  would  have  supposed 
had  been  incorporated  with  their  very  nature,  but 
men  seem  actually  to  take  pleasure  in  being  careless, 
and  comment  upon  the  little  need  of  corporeal  ablu- 
tions. Days  pass  without  the  use  of  water,  and  filth 
and  vermin  soon  reign  triumphant.  It  requires  time  to 
prove  to  volunteers  the  fallacy  and  dangers  of  such  a 
coarse,  which  a  sail  experience  corrects.    The  result  of 

this  carelessness,  during  the  first  year  of  the  war,  was 
that    lice,  which   are    an  accompaniment  of  armies, 


30  CLEANLINESS    NECESSARY    FOR    HEALTH. 

were  do  Btrangera  to  out  Boldiera.  The  were 
covered  with  them,  and  infected  all  their  b 
from  the  genera]  to  the  private,  and  only  with  t lie 
utmost  care  could  the  cleanly  keep  bhems< 
from  iliis  disgusting  companionship.  One  of  the 
strongest  reasons  why  regalara  enjoy  better  health 
than  volunteers,  ia  thai  the  one  are  daily  insp 
by  their  officers,  who  insist  upon  their  focea  being 
washed,  heads  combed,  etc.;  while  the  volunteers, 
with  whom  the  regulations  of  s  Btriol  discipline  are 
not  enforced,  are  allowed  to  abuse  the  privilege  of 
following  l ho  bent  of  their  own  inclinations.  In  the 
beginning  of  the  war  it  was  deplorable  to  Bee  the 
condition  of  our  besl  society  in  camp.  Then,  in  the 
Confederate  hospitals,  it  waa  r»->t  rare  to  administer 
the  first  hath  to  volunteers  who  had  been  six  months 
in  service,  without  ever  having  used  water  beyond 
their  (aces.  It  would  be  a  sanitary  regulation  of 
great  value,  it'  general  ablutions  could  be  made  a  por- 
tion of  the  daily  drill.  A  heavy  penalty  of  extra 
fatigue  duty  should  be  imposed  upon  those  who  did 
the  requirements  of  hygiene  and  clean- 
liness.    A.B  the  in Baity  for  a  more  rigid  discipline 

haa    bee  .me   apparent    both    to   Officers   and    men.    the 

linea  have  been  gradually  drawn,  until  at  present  our 
army  of  volunteers,  with  indep  indent  views  of  the 
duties  and  obligations  of  soldiers,  have  imperceptibly 
d  into  a  bo  !y  of  regulars,  governed  by  those 
strict   rules  which  military  experience  has  shown  iu- 

dispensable  tO  the  sanitary  condition  Of  ail  army  ;  and 

hygiene,  in  all  of  its  details,  is  now  much  more  carer 
fully  observed.     The  frequent  in  an  of  stall' oili- 

er-- have  stimulated  both  medical  and  line  omoers  to 
a  more  rigid  performance  of  their  duties,  and  hygienic 

regulation-    are    now    enforced.      He    is    not    only    the 


FOOD    FOR    SOLDIKRS.  31 

best,  but  also  will  becomo  tbe  most  popular  officer, 
who  attends  himself  to  all  these  detailed  comforts  of 
his  men. 

Pood  of  the  soldier  should  be  plain,  nutritious  fare, 
well  cooked,  which,  with  exercise  as  an  appetizer,  he 
will  find  no  difficulty  in  enjoying,  however  monoto- 
nous his  daily  ration  may  be.  For  a  working  man 
(and  where  do  men  labor  more  than  the  soldier  in  the 
field?)  the  diet  should  be  of  a  mixed  character,  and 
food  should  be  of  the  variety  easily  cooked.  The 
character  of  the  diet,  however,  must  depend,  to  a 
certain  extent,  upon  the  seasons,  and  the  ability  of  the 
commissary  to  meet  the  demands  of  the  army.  High- 
ly-seasoned dishes  are  neither  possible  nor  desirable 
for  the  soldier!  Toil,  fatigue,  and  often  hunger,  will 
make  any  wholesome  food  savory.  "The  plain  repast 
is  sufficient  for  sustenance;  and  a  plain  repast  gives 
all  the  gratification  to  the  palate  of  a  hungry  and 
thirsty  man  that  a  soldier  ought  to  permit  himself  to 
receive."* 

For  the  English  there  is  no  beverage  like  tea;  and 
a  military  writer  remarks  that  a  breakfast  of  tea, 
with  bread,  enables  a  person  to  sustain  the  Fatigues 
of  war  with  more  energy  and  endurance  than  a 
breakfast  of  beefsteak  and  porter.  The  French  pre- 
fer coffee,  to  which  they  give  the  highest  prophyln 
tic  virtue.  This  is  the  stimulating  drink  of  the 
troops,  and  its  free  use  makes  the  men  much  more 
healthy  and  cheerful. 

A-   neither  coffee  nor  tea  can  bo  obtained  by  OUT 

troops,  inasmuch  as   the  stringency  of  the  blockade 

udes   i"'!h    of   tii.~..   articles    from    commissary 

stores  |  except  in  sum II  quantity  for  hospital  use),  whis- 

•Jarksun'  f  Armies. 


32  FOOD    FOR   SOLDI! 

key  at  times  becomes  a  necessary  issue  to  sustain  the 
health  of  the  army  under  Bevere  trials. 

The  Turks  place  great  reliance  on  coffee  as  a  pre- 
servative I  dysentery ;  and  BicLeod  states,  as  a 
N  Bull  of  hie  Crimean  experience  :  "  I  have  no  <l<>ubt 
that,  if  the  precaution  had  been  taken  to  Biipply  the 
troops  every  morning  with  1  *  * » t  coffee,  as  they  went  on 
or  returned  from  doty,  much  of  our  mortality  might 
have  been  avoided." 

As  roasted  and  ground  coffee  has  become  a  tixe<l  ar- 
ticle of  trade,  it  would  be  much  better  for  the  troops 
if  it  could  be  served  out  in  this  form,  mixed  with  a  due 
proportion  of  Bugar,  particularly  when  they  are  upon 
extra  duty,  as  it  not  only  Bavee  them  much  time,  but 
insures  the  proper  preparation  of  a  supporting  bever- 
age. 

[f  coffee  can  not  be  obtained,  the  best  substitute  is  a 
pint  of  hot  Boup,  which  might  be  prepared  from  fresh 
beef  when  thia  article  is  abundant ;  but,  what  is  still 
better  for  army  purposes,  from  a  Bpiced  Boup-cake, 
which  is  made  of  choice  portions  of  beef,  farinaceous 
ingredients, and  spices — the  whole  cooked, compressed, 
and  desiccated.  These  cakes  occupy  but  a  small 
space,  can  be  easily  carried,  will  keep  for  months: 
and,  by  cutting  them  uj>  in  the  proportion  of  a  pint  of 

boiling  water    for  each  Cake,  and    allowed    to  hoil    for 
ten  or  tilt ee n  minutes,  a  pint  Of  excellent .  well -lluvoivd 

ip  can  be  made.  It  requires  no  longer  to  make  a 
pint  of  good  soup,  with  one  of  Jones'  soup-cakes,  than 
would  be  required  to  make  a  cup  of  coffee,  with  the 
coffee  already  parched  and  ground. 

On  account  of  the  very  great  exposure  to  which  our 
troops  must  submit,  without  the  protection  of  tents  to 
shield  them  from  the  drenching  rains  or  the  heavy 
nightly   dews,  when    it   could    be   obtained,  a  dram  of 


FOOD    FOR    B01UIEB8.        ■  .'53 

whiskey,  issued  as  a  ration,  has  been  found  very  ben- 
eficial in  sustaining  the  health  of  our  men.  From 
the  scarcity  of  this,  with  all  other  stimulants,  its  use 
has  not  been  general,  nor  continued  for  any  length  of 
time  ;  but  when  it  could  be  procured,  the  advantages  of 
the  issue  were  veiy  decided.  In  the  malarial  region 
upon  the  coast  of  South  Carolina,  among  the  swamps 
and  rice  fields  of  this  very  insalubrious  country,  a 
daily  issue,  during  the  summer  months  of  1862,  of 
whiskey  medicated  with  an  infusion  of  tonic  barks, 
was  found  to  produce  the  most  decidedly  beneficial 
effects  on  the  appearance  and  condition  of  the  men — 
filling  the  ranks,  and  improving  the  physique  of  com- 
panies—  when,  before  its  use,  the  force  of  the  regi- 
ments, broken  up  by  climatic  diseases,  was  represented 
only  in  hospitals. 

It  may  be  needless  to  say  that  good  water  is  even 
more  necessary  than  good  food,  and  should  be  ob- 
tained, at  any  cost,  for  the  use  of  the  troops.  There  is 
no  one  item  so  prolific  in  disease  as  drinking  bad 
water — so  strikingly  exemplified  in  the  Western 
Army  at  the  time  of,  and  after,  the  Battle  of  Shiloh, 
when,  from  tbe  scarcity  of  good  water,  and  the  filthy, 
muddy  condition  of  the  little  which  could  be  obtained, 
an  epidemic  of  diarrhoea  and  dysentery,  with  typhoid 
complications,  decimated,  and  at  one  time  threat- 
ened to  destroy  our  army.  Should  troops  be  so 
Unfortunate  as  to  be  in  a  place  where  stagnant  or 
ditch  water  has  to  be  used,  it  can  be  purified  by  boil- 
ing with  a  luinj)  of  charcoal;  after  which  it  should  lie 
freely  agitated  in  the  air,  to  restore  to  it  the  vivifying 
properties  which  the  heat  had  driven  off.  Should  the 
water  he  turhid.a  pieceofalutn  thrown  into  a  hucket- 

ful  will   quickly  settle  the   deposit  and   restore   its 

crystalline  character.      If   more  time    be  allowed,    the 


8  I  FOOH    KOR    SOLDIERS. 

better  plan  would  be  to  filter  the  water  by  Sinking  a 
barrel  with  holes  bored  in  the  side;  into  this  a  much 
smaller  barrel,  with  the  bottom  knocked  out,  is  placed, 
and  the  intervening  Bpace  between  the  barrels  filled 
with  Straw.  The  water  which  passes  through  the 
holes  leaves  all  imparities  upon  the  straw,  and  springs 
Up  a-  dear,  potable  water  in  the  smaller  barrel. 

Fresh  meat  is  a  frequent  issue  to  armies,  and  is  the 
m<>st  common  issue  to  our  troops.  It  is  usually  boiled 
or  roasted  over  the  fire  into  a  tough  mass,  known  as 
frizzled  beef,  which  tests  the  capacity  of  even  a  sol- 
dier's digestion.  The  proper  mode  of  cooking  this 
ration  is  in  soup,  which  is  always  palatable,  whether 
thickened  with  flour,  hard  bread,  or  such  vegetables  as 
the  country  affords.  A  French  military  proverb  says 
that  "Soup  makes  the  Boldier."  In  the  use  of  fresh 
meat,  let  it  always  he  remembered  that  a  fundamental 
rule  in  the  culinary  art  is  to  boil  meat  slowly  and  roast 
it  quickly. 

The  Tree  use  ol  fresh  vegetables  is  the  only  mode 
of  preventing  the  appearance  of  scurvy  among  tho 
troops.  When  these  can  not  be  obtained,  the  free  use 
of  dried  vegetables,  as  rice,  potatoes,  corn  meal,  etc., 
will  tend  lo  sustain  health  and  vigor. 

A  distinguished  military  surgeon  has  remarked  that 
lo  1,000  francs  spent  in  fresh  vegetables  will  save 
500,000  franCS  from  the  expenses  of  sick  soldiers  en- 
tering    the    hospital,    beside    the    use    of     the    men    for 

active  service.  Of  the  dried  vegetables,  rice  is  among 
thebesl  for  feeding  troops.     It  is  easily  carried,  easily 

I.  easily  digested,  and  is  one  of  the  most  whole- 
some of  the  farinaceous  articles  -correcting,  as  it 
often  does,  the  tendency  to  intestinal  fluxes,  and  yet 
in  the  rice-growing  country  of  the  Confederate  States 
it  is  issticil    very  sparingly  to  our  troops. 


FOOD    FOR    SOLDIERS.  35 

In  the  Crimea,  where  the  temporary  absence' of 
fresh  vegetables  was  a  great  and  serious  privation, 
lime-juice,  citric  acid,  and  sour-crout  were  extensively 
used  to  prevent  and  stop  scurvy.  Acid  fruits  are  anti- 
scorbutic, and  veiy  good  for  soldiers.  The  English, 
in  the  Crimea,  gave  out  a  ration  of  lemon-juice  three 
times  a  week,  which,  when  mixed  with  rum  and  sugar, 
made  a  very  nice,  healthy  drink.  This  corrective 
protected,  to  a  certain  extent,  the  English  soldiers 
from  scurvy,  while  with  the  French  it  was  widely 
epidemic  and  very  fatal.  Vinegar,  when  freely  dis- 
tributed, also  assists  in  preventing  this  scourge  among 
troops.  Vinegar,  molasses,  and  water,  when  mixed  in 
proper  proportions,  make  a  veiy  refreshing  and  palat- 
able drink,  not  unlike  lemonade,  and  possessing 
similar  antiscorbutic  properties  to  lemon-juice. 

Scurvy  has  often  appeared  in  our  armies,  and  during 
the  spring  of  1863  it  was  quite  prevalent  in  the  Army 
of  the  Potomac.  It  was  corrected  by  the  issue  of 
antiscorbutics,  but  more  especially  by  the  use  of  wild 
herbs,  which  were  collected  by  men  sent  out  for  that 
purpose.  With  beef  and  the  herbs  an  excellent  soup 
was  made,  which  was  found  the  best  corrective  for  the 
scorbutic  symptoms. 

One  of  the  worst  articles  which  can  be  issued  to 
troops  in  the  Held,  without  conveniences  for  cooking, 
is  wheat  flour.  Fresh  bread  all  will  acknowledge  to 
be  good  tare,  and  is  always  hailed  with  satisfaction; 
but  to  issue  raw  Hour  as  the  vegetable  element  of  a 
ration,  with  no  means  of  cooking  it  into  an  edible 
bread,  is  an  act  of  cruelty  to  troops  who  have  no 
nvaiis  .it'  obtaining  other  food  than  that  which  the 
commissary  department  allows.  In  our  corn  country, 
where  corn  meal  or  grist  is  a  common  article  of  food, 
8  staple   liked  by  all,  and  the  mode  of  cooking  it  easy 


36  FOOH    P>R    SOLDI! 

And   familiar — tin-  article  itself  abundant,  cheap, 
forming  the  very  best  of  food  for  man — why  this  article 
should   not  be   generally  issued  instead  of  unwhole- 

b e  flour,  which  can  only  be  made  into  the  most 

indigestible  of  dough-cakes,  into  which  the  teeth  stick 

in  vain  attempts  at   mastication,  can  not   bo  satis: 

rilv  explained.  Economy,  the  health  of  the  troops, 
and  general  satisfaction  in  the  army,  would  be  the  re- 
sult of  the  change  from  wheat  flour  to  corn  meal.     If 

orders  were  issued    to  carry    portable  ovens  with    the 

troops,  so  thai   g 1   bread  could  be  daily  prepared, 

which  '-an  very  easily  be  done,  or  if  ovens  were  built 
wherever  troops  locate,  then  would  flour  be  a  useful 
issue. 

Bi8CnitS,  Or  hard  bread,  is  B  common  article  of  diet 
ill  camp  life,  because  it  is  easily  preserved  and  trans- 
ported.     When    eaten    as    dry     biscuit,    it    acts    like    il 

Bponge  in  the  mouth,  exhausting  salivary  Becretion. 
When  possible]  and  rarely  is  it  inconvenient,  soak  it 
in  tea,  coffee,  or  SOUp ;   it  then  makes  a  very  nutritious 

meal.  Even  water,  with  a  little  salt,  makes  hard 
bread   much   more  palatable  ami  nourishing.     When 

boiled  with  -diced  bacon  and  water  it  is  a  very  satis- 
factory meal  for  our  Boldiers,  one  always  relished,  hut 

not  very  often  enjoyed. 

Necessity,  the  parent  of  everything  useful,  even  in 
the  domestic  economy  of  armies,  has  driven  our  sol- 
diers to  a  method  of  using  their  Hour  ration  which,  in 
absence  of  other  fare,  make-  a  palatable  and  an  edi- 
ble bread,  which  is  known  in  t  lie  army  as  Confederate 
Biscuit.     It  is  prepared  as  follows :     Cooking  utensils 

being  of  the  most  simple  eh  a  racier  and  of  the  smallest 

possible  number  in  our  army,  a  mess-pan,  camp-kettle, 

or  even  tin  cup,  is  often  found  to  embody  all  the  re- 
quisites   for   conking    the    daily    meals.      Where  extra 


FOOD    FOR    SOLDIERS.  37 

cooking  is  desired,  apparatus  must  be  improvised.  A 
piece  of  bark  or  the  bend  of  B  barrel  composes  tbe 
kneading-trough,  upon  winch  tbe  flour  is  worked  with 
salt  and  water,  or  with  melted  grease,  when  the  beef 
issued  can  supply  tallow.  This  muss  is  either  baked 
or  fried  in  a  pan;  or,  drawn  out  as  a  cord,  is  twisted 
around  a  ramrod,  and  baked  over  tbe  fire.  When  tbe 
army  is  moving,  and  cooking  utensils  can  not  be  got 
at,  a  bole  scooped  in  the  ground  with  a  bayonet 
makes  a  ready  mixing-bowl,  and  tbe  ramrod,  always 
at  band,  completes  tbe  paraphernalia  of  the  kitchen. 
The  bread  made  in  this  way  is  reported  excellent. 
Fresh  bread  is  always  preferable,  when  it  can  be  ob- 
tained. 

Bacon  is.  par  excellence,  the  laborers'  and  soldiers' 
meat  in  America,  and  goes  further,  by  weight,  than 
any  other.  It  never  produces  surfeit,  is  always  ac- 
ceptable, very  easily  cooked,  and.  with  its  rich  juice, 
will  make  the  dryest  farinaceous  diet  savory.  It  has 
the  very  great  advantage,  when  properly  cured,  of 
keeping  for  a  length  of  time,  under  any  condition, 
which  makes  it  far  preferable  to  any  other  meat  for 
troops.  It  can  also  be  eaten  raw,  as  on  a  march, 
when  neither  time  nor  convenience  exists  for  cooking 
it  <  >ur  soldiers,  who  are  very  often  forced  to  this  al- 
ternative, have  not.  apparently, suffered  from  its  very 
frequent  repctil  ion. 

In  the  Confederate  service,  the  full  ration,  which  our 
troops  have  seldom  issued  to  them,  consists  of  three- 
quarters  of  a  pound  of  pork  or  bacon,  or  one  and  one- 
quarter  pounds  Of  fresh  or  salt   beef ;    eighteen  ounces 

of  bread  or  flour,  or  twelve  ounces  of  biscuit,  or  one 
and  one-quarter  pounds  corn  meal  ;  and  at  the  rate, 
to  one  hundred  rations,  of  eight  quarts  of  p< 

beans,  or.  in  lieu  thert  of,  ten  j  ounde  ix  pounds 


n  ::    SOLDIERS. 

of  coffee,  twelve  pounds  of  Bugar;  also,  four  quarts  of 
vinegar.  The  ration  is  completed  by  adding  one  and 
one-half  pounds  of  tallow,  one  and  one-quarter  pounds 
of  adamantine,  or  one  pound  of  Bperra  candles,  four 
pounds  of  soap,  and  two  quarts  of  salt,  to  one  hundred 
ration-.  <  >n  a  campaign,  or  on  marches,  or  on  board 
transports,  the  ration  of  hard  bread  is  one  pound. 

Extra  issues  of  soap,  candles,  and  vinegar  are  per- 
mitted (<>  the  hospital,  when  the  Burgeon  does  not  avail 
himself  of  the  commutation  of  the  hospital  rations.  or 
when  there  is  no  hospital  fund. 

Desiccated  vegetables  may  be  issued  onceperweek, 
in  lieu  of  beans  <>r  rice;  and  should  a  tendency  to 
scurvy  appeal-  among  the  troop-,  the  commanding 
officer  may.  by  advice  of  the  medical  officer,  direct 
their  more  frequent  issue.  Two  "issues"  per  week  of 
"desiccated  vegetables"  may  be  made  in  lieu  of  beans 
or  rii 

Potatoes  and  onions,  when  used,  will  always  be  in 
lieu  of  rice  or  l>cans.  Potatoes  at  the  rate  of  one 
pound    p'l-   ration;   onions  at    the    rate   of  three   pecks 

per  hundred  rations. 

When  fresh  beef  can  be  provided, so  a-  to  eosl  not 
more  than  an  equivalent  of  salt  pork,  it  i-  issued  to  the 
troops  five  times  a  week,     it  ha-  often  occurred  that 

beef  was  the  sole  meat  issue  for  weeks  continuously, 
and  as  often  the  army  would  he  for  days  without  an 
issue  of  meal  of  any  kind — hard  biscuit  or  wheat  flour 
being  the  -ole  article  of  food  used.  Often  has  a  few 
ear-  of  corn  to  man  and  horse  been  the  day's  ration  in 
our  army. 

When,  from  excessive  fatigue  or  exposure,  the  com- 
manding officer  may  deem  it  necessary,  he  may  direct 
the  issue  of  whiskey  to  the  enlisted  men  of  Ids  com- 
mand, nut  to  exceed  a  gill  per  man  for  each  day. 


FOOD    FOR   SOLDIERS  39 

Tea  may  be  issued  in  lieu  of  coffee,  at  the  rate.of  one 
and  a  half  pounds  per  hundred  rations. 

When  the  officers  of  the  medical  department  find 
antiscorbutics  necessary  for  the  health  of  the  troops, 
the  commanding  officer  may  order  issues  of  fresh  vege- 
tables, pickled  onions,  sour-crout,  or  molasses,  with  an 
extra  quantity  of  rice  and  vinegar;  potatoes  are 
usually  issued  at  the  rate  of  one  pound  per  ration,  and 
onions  at  the  rate  of  three  bushels  in  lieu  of  one  of 
beans.  Occasional  issues  (extra)  of  molasses  arc  made 
— two  quarts  to  one  hundred  rations;  and  of  dried 
apples,  of  from  one  to  one  and  a  half  bushels  to  one 
hundred  rations. 

When  antiscorbutics  arc  issued,  the  medical  officer 
will  certify  the  necessity  ami  the  circumstances  which 
cause  it.  upon  the  abstract  of  extra  issues. 

Such  arc  the  supplies  which  our  troops  would  be  al- 
lowed tohave  in  peacetimes,  and  in  the  beginning  of  the 
war  most  of  the  articles  may  have  been  issued;  but  the 
army  has  not,  for  many  months,  enjoyed  the  privilege 
of  whetting  their  appetites  upon  this  attractive  bill  of 
fare  of  the  commissary-general's.  Habit  has  taught 
them  to  live  upon  a  much  smaller  list,  and  in  much 
smaller  quantity.  From  the  scarcity  of  many  of  the 
articles  enumerated  above,  they  have  been  rescinded 
from  the  issue,  and  the  ration  has  been  reduced  to  its 
simplest  form  "f  beef  and  Hour.  Owing  to  a  badly- 
organized  and  deficient  transportation, one  portion  of 
the  army  i-  surfeited  with  such  things  as  another 
division  seldom  sees.  Notwithstanding  the  scanty 
and  very  indifferent  fare,  our  veteran  troops,  who  have 
become  accustomed  to  it.  sustain  robust  health. 

Daily  it  Uions  should  hi-  made  to  the  troops; 

for  when,  from  the  laziness  of  coma  two  <>r 

three  days  rations  are  given  out  at  a  time,  through 


40  PREPARING    RATIONS. 

the  proverbial  carelessness  or  improvidence  of  soldie 
the  provisions  arc  either  wasted  or  all  are  eaten  in  one 
•  lav,  and  two  days'  starvation,  if  not  sickness  from  gor- 
mandizing, follows. 

As  soldiers  are  expected  to  cook  their  own  pro. 
visions,  and  as  all  are  familiar  with  the  fact  that  as 
much  depends  upon  the  mode  of  cooking  as  upon  the 
articles  cooked,  it  would  be  better  to  have  one  of  the 
mess  appointed  special  cook  than  to  allow  the  soldiers 
to  cook  in  turn.  A  division  of  labor  is  clearly  the 
preferable  plan.  It  would  be  economical  and  benefi- 
cial, if  government  would  allow  two  professed  cooks 
for  each  company,  as  the  health  of  the  army  would 
be  improved  materially  by  having  good  tare.  Fire- 
wood, of  course,  must  be  liberally  provided,  as  it  is 
one-half  of  a  soldier's  existence. 

The  entire  health  of  troops  depends  upon  the 
quality,  quantity,  variety,  and  the  regularity  with 
which  the  provisions  are  supplied.  The  effective 
condition  and  strength  of  the  army,  with  a  diminu- 
tion of  the  sick-,  and  consequently  a  diminution  in  the 
hospital  expenses,  will  depend,  in  a  great  measure, 
upon  the  commissary  department.  In  1847  the  high 
price  of  provisions  doubled  the  number  of  sick  in  tho 
French  army,  sending  one-fifth  of  the  effective  regi- 
ments into  the  hospitals.  The  better  paid,  select 
corps,  who  could  increase  their  supply  of  nourish- 
ment, escaped  those  diseases  which  prevailed  among 
the  common  soldiers.  Fxperienco  shows  that,  in  a 
besieged  city,  when  scarcity  prevails,  pestilence  fol- 
lows in  the  wake  of  famine. 

Officers  as  well  as  soldiers  usually  club  together 
into  messes,  which  is  not  only  more  agreeable,  but 
also  profitable  for  all  concerned. 

Officers'  messes  should  consist  of  tho  company  offi- 


Messing.  41 

cers — four  persons.  The  colonel,  lieutenant-colonel, 
major,  adjutant,  and  sergeant-major,  with  the  com- 
missary, quartermaster,  surgeon,  assistant  surgeon, 
and  chaplain,  could  easily  arrange  two  or  three 
messes. 

Messes  of  privates  and  non-commissioned  officers 
should  number  six  persons,  for  obvious  reasons,  so 
that  the  details  for  guard  duty  would  always  leave 
four  in  charge  of  the  tent. 

Articles  wanted  for  a  mess  of  six,  when  transpor- 
tation is  abundant,  and  articles  readily  obtained  :  Two 
champagne  baskets,  covered  with  coarse  canvas,  with 
two  leather  straps  with  buckles;  six  tin  plates;  six  tin 
cups;  mx  knives  and  forks;  six  bags  for  sugar,  coffee, 
salt,  etc.,  to  hold  from  half  a  gallon  to  one  gallon; 
one  large-size  camp-kettle,  one  iron  pot,  one  bake- 
oven,  one  frying-pan,  one  water-bucket,  one  lantern, 
one  coffee-mill,  six  spoons,  one  tin  salt-box,  one  tin 
pepper-box,  two  butcher-knives,  two  kitchen-spoons, 
two  tin  dippers,  one  teapot,  one  coffee-kettle.  Two 
years'  experience,  the  rapid  movements  of  our  army, 
and  deficient  transportation,  with  the  impossibility  of 
supplying  the  wear,  tear,  and  loss  of  camp  utensils, 
have  modified  the  list  of  necessary  culinary  articles, 
and  our  soldiers  are  now  accustomed  to  prepare  their 
rations  with  very  little  in  the  shape  of  cooking  uten- 
sils. If  each  man  has  a  tin  cup,  and  each  company  a 
camp-kettle,  one  or  two  frying-pans,  and  an  axe  to 
cut  wood  with,  they  would  consider  themselves  well 
provided  with  all  necessary  apparatus.  In  the  present 
condition  of  the  cooking  utensils  of  our  army,  one 
wagon  readily  carries  the  cooking  paraphernalia  ot 
a  regiment. 

It  is  always  a  good  rule  to  accustom   an   army  to 
adopt  the  modes  of  living  common  to  the  inhabitants 
D 


42  PREPARATION    POU    MARCHING. 

of  the  country  in  which  the  army  is  found,  as  certain 
peculiarities  of  living  are  naturally  adapted  to  cer- 
tain climates. 

Although  war  brings  with  it  privations  and  irregu- 
lar living,  which  it  is  impossible  to  prevent,  the  mode 
of  living  of  a  soldier,  to  a  certain  extent,  should  fol- 
low a  fixed  standard.  His  meals  should  be  equally 
distributed  through  the  day,  and  he  should  never  ho 
put  to  work  without  having  broken  his  fast,  however 
light  the  meal  be.  In  camp,  soldiers  should  live  with 
regularity,  and  the  breakfast  and  dinner  hour  should 
be  respected;  and  as  three  meals  a  day  is  the  custom 
of  our  people,  this  regulation  should  be  adopted.  It 
is  on  the  march  that  circumstances  prevent  the  car- 
rying out  of  rules,  and  that  our  troops  suffer  the 
greatest  privations.  Very  few  armies  have  been  more 
exposed,  and  suffered  more  from  hunger  and  fatigue, 
with  so  little  dissatisfaction  and  straggling  as  ours. 

The  following  is  the  order  which  experience  has 
proved  to  be  the  most  useful  in  the  Confederate  army: 
Our  troops  are  accustomed  to  move  at  short  notice, 
and,  therefore,  often  with  empt}^  haversacks,  and  no 
prospect  for  a  meal  dining  the  day.  When  a  march 
has  been  determined  upon,  the  ration  (which  is  now 
one  pound  of  flour  and  half  pound  of  bacon,  the  latter 
being  usually  issued  in  lieu  of  beef  when  troops  are 
under  marching  orders)  is  cooked  in  advance,  or 
bread  may  be  issued,  which,  with  raw  bacon,  will 
make  a  palatablo  meal.  Usually,  three  days  rations 
are  served  and  cooked  prior  to  moving,  and  under 
these  conditions  a  hasty  meal  will  be  taken  before 
falling  into  line.  Our  men  have  neither  the  hot  cup 
of  coffee  or  tea,  nor  have  they  the  hot  soup,  nor  drink 
of  whiskej',  which  is  tho  inarching  preparation  of  an 
army  with  a  more  extensive  commissariat  than  ours. 


ORDER    IN    MARCHING.  43 

They  move  with  alacrity,  and  often  break  their  fast 
while  in  motion.  The  start,  especially  in  summer, 
should  always  bo  at  the  break  of  day.  After  march- 
ing three-fourths  of  an  hour,  the  column  stops  for 
twenty  minutes.  In  resuming  the  march,  a  halt  is 
made  for  ten  minutes  after  each  hour.  From  twenty 
to  twenty-five  miles  a  day  is  considered  good  march- 
ing for  an  army,  although,  on  an  average,  it  does  not 
exceed  fifteen,  and  may  l>e  divided  in  the  following 
order:  Nearly  three  miles  maybe  made  during  the 
first  hour  of  marching;  then  a  halt  is  ordered  for 
twenty  minutes,  during  which  the  men  should  remove 
their  knapsacks  and  recline  upon  the  ground,  as 
standing  gives  but  little  relief.  Two  miles  an  hour 
can  be  made  for  the  remaining  portion  of  the  da}^. 
After  marching  for  three  or  four  hours,  a  halt  should 
be  ordered,  especially  in  summer,  until  the  heat  of  the 
day  passes,  when  the  march  may  be  resumed.  During 
the  mid-day  rest,  if  any  opportunity  exists,  the  shoes 
and  stockings  should  be  removed  and  the  feet  bathed, 
which,  by  removing  dirt  and  acid  secretions,  will  pre- 
vent excoriations.  It  may  also  bo  advantageous,  at 
such  times,  to  change  socks  from  one  foot  to  the 
other,  so  that  the  seams  may  come  at  different  por- 
tions of  the  foot,  which  will  prevent  continued  and 
injurious  pressure.  Soaping  the  sock  will  also  pre- 
vent excoriations,  and  add  much  to  the  comfort  of  a 
soldier  while  on  a  march. 

In  crossing  a  river,  when  there  arc  no  bridges,  the 
men  ford  it,  and  continue  the  march  in  their  wet- 
clothes,  until  they  dry.  It  is  found  that  when  they 
arc  allowed,  as  they  are  in  European  armies,  to  take 
oil  their  pantaloons  and  shoes,  that  much  delay  is  oc- 
casioned, and  the  column  is  thrown  thereby  into  dis- 
order.     A    sentinel    guards    any    fresh- water    spring 


44  ORDKK    IN    MARCHING. 

which  i.s  met  in  the  march,  to  deter  soldiers  from 
gorging  themselves  —  a  very  wise  measure,  which 
prevents    much   sickness.      An  aphorism    worthy   of 

remembrance  is — Brink  always  before  marching^  and 
while  on  the  march  moisten  the  month  often,  bat  drink 
Seldom.  Water  should  always  be  taken  in  reserve, 
and  with  precaution.  When  taken  in  great  quan- 
tities, it  weakens  and  fatigues  the  organs  of  digestion, 
increases  perspiration,  and  enervates  the  entire  sys- 
tem. It  is  particularly  injurious  to  drink  rapidly  and 
freely  when  heated  from  exercise,  as  sudden  death 
sometimes  follows  this  imprudence. 

The  soldier  should  accastom  himself,  when  thirsty, 
to  drink  slowly  and  in  small  monthfals,  keeping  the 
water  in  the  mouth  and  throat  as  long  as  possible. 
The  cravings  of  thirst  are  often  produced  by  a 
parched  condition  of  the  lining  membrane  of  the 
mouth;  and  by  rinsing  the  mouth  frequently,  thirst 
can  be  allayed  to  such  a  degree  that  but  little  water 
will  be  required,  while  much,  hurriedly  drank,  will 
not  satisfy  the  urgent  call.  In  marching,  thirst  can, 
in  a  measure,  be  prevented  by  keeping  the  mouth 
closed,  and  in  speaking  as  seldom  as  possible;  other- 
wise, the  dry  air,  often  loafled  with  dust,  will  parch 
the  lining  membrane  of  the  mouth — a  very  distress- 
ing sensation  when  it  can  not  be  relieved  by  drinking. 
Arabs,  in  crossing  sandy  deserts,  where  but  little 
water  can  bo  found  to  allay  the  intense  thirst  of  their 
hot  climate,  adopt  the  wise  precaution  of  tying  a 
handkerchief  over  the  mouth,  which  keeps  out  dust, 
and,  by  preventing  conversation,  prevents,  to  a  great 
extent,  thirst.  It  would  be  well  for  troops  upon  a 
march  to  profit  by  their  experience. 

When,  during  a  march  or  halt,  the  fatigued  and 
thirsty  soldier  finds  water,  instead  of  rushing  to  it  at 


ORDER    IN    MARCHING.  45 

once,  he  should  first  try  and  repose  himself  before 
drinking;  then,  having  washed  out  his  mouth  several 
times,  drink  slowly,  so  as  to  make  the  smallest  possi- 
ble quantity  of  water  supply  his  necessities.  Wash- 
ing the  face  slackens  thirst.  When  water  can  not  be 
Obtained,  a  bullet  or  pebble  in  the  mouth,  or  chewing 
a  green  leaf,  will  cause  a  secretion  of  ^saliva,  and,  by 
keeping  the  mouth  moist,  will  temporarily  allay 
thirst.  As  good  water  is  not  always  to  he  obtained 
on  a  march,  a  soldier  should  never  lose  an  oppor- 
tunity for  filling  his  canteen  with  fresh  water.  If  the 
canteeus  be  covered  with  a  light-colored  woollen  cloth 
the  water  will  keep  cooler  than  in  bright  tin,  which 
absorbs  heat  more  rapidly,  and  extends  it  to  the  con- 
tents of  the  canteen. 

When  troops  have  had  an  early  start,  and  are  not 
marching  in  the  face  of  an  enemy,  they  should 
bivouac  about  ten  o'clock  in  the  morning,  and  lie 
over  during  the  heat  of  the  day,  as  soldiers  on  a 
march  should,  if  possible,  be  protected  from  the  mid- 
day sun.  Here  they  will  have  time  to  cook  their 
mid-day  meal,  and  refresh  themselves  from  their 
fatigue.  The  experienced  soldier  never  forgets  to 
keep  in  reserve  a  certain  proportion  of  meat  or  other 
food,  against  a  deficient  distribution,  or  the  want  of 
time  for  properly  preparing  it,  during  the  continued 
march.  The  want  of  this  precaution,  which  old  sol- 
diers adopt,  is  severely  felt  by  recruits.  The  meal 
should  be  taken  in  the  shade,  under  some  protection 
from  the  sun.  A  few  branches,  properly  arranged, 
will  form  a  comfortable  shelter.  The  main  meal  of 
meat,  etc,  should  be  taken  alter  the  evening  halt,  at 
the  end  of  tin-  day  V  march. 

The  officer  in  charge  of  the  troops  should  always 
know   the  road  over  which  he  is  to  travel  the  next 


46  BIVOUAC  KINO    DURING    A    MARCH. 

day,  : * ii*l  when  he  is  compelled  t<>  bivouac  in  placos 
where  the  prospect  t''>r  getting  wood  is  bad,  each  sol- 
dier  should  carry  on  his  knapsack  a  small  quantity  to 
cook  his  mid-day  meal  with. 

W 1 1 > ■  1 1  troops  are  ordered  on  a  forced  march,  or  <>m 
scouting  service,  their  food  should  be  prepared  in 
advance,  for  t\\"  or  three  days  rations,  or  they  should 
be  furnished  with  Buch  as  can  be  rapidly  cooked ; 
sausage  or  meat-cakes,  with  biscuit,  would  be  an 
llent  issue  at  Buch  times. 

Tu  the  evening  halt,  which  should  beat  about  live 
o'clock  iii  the  afternoon,  bo  as  to  allow  the  men  to 
improvise  camp  comforts,  the  site  selected  for  the 
camp,  when  possible,  should  be  on  iisin^  ground,  free 
from  low  places,  and  in  proximity  to  water  and  wood. 
These  rules  become  of  special  importance  in  estab- 
lishing a  camp  for  even  a  few  days'  stay.  It  is  pru- 
dent to  avoid  the  immediate  vicinity  of  swamps  and 
rivers;  the  emanations  from  such  are  noxious,  often 
pestilential,  but  fortunately  do  not  extend  to  a  great 
distance.  Interposing  a  piece  of  rising  ground  or 
wood  is.  as  a  general  rule,  sufficient  to  turn  or  break 
currents  from  these  low  places, and  protect  from  their 
hurtful  influence.     It  would  Wc  preferable  to  camp  in 

tbe  direction  Of  the  regular  wind  currents,  so  that 
emanations  may  be  wafted  in  the  contrary  direction. 
When  i  he  halt  i--  only  for  tho  night,  although  the 
camp-wagons,  with  the  tents  for  the  officers,  may  have 
come  up,  they  prefer,  with  the  men,  to  bivouac  under 
tbe  clear  sky,  or  geek  shelter  under  a  few  branches, 
with  which  they  form  a  rough  shfed  that   will  protect 

them  from  dew.  'The  bivouac  is,  from  necessity,  the 
mode  of  living  of  most  of  our  troops  during  the  active 
campaign,  which  extends  over  several  months  of  each 
year.     At  tbe  breaking  up  of  the  winter  encampment, 


i 


BIVOUACKING    DURING    A    MARCH.  47 

all  tents,  with  the  exception  of  a  few  for  the  use  of 
officers,  are  turned  over  to  the  quartermaster,  to  bo 
transported  to  some  depot  in  the  rear,  where  they 
remain,  unless  the  army,  in  maneuvering,  occupies 
a  position  which  it  will  retain  for  a  lengthened 
period,  when  the  tents  are  again  issued.  As  our 
troops  move  with  celerity,  and  as  transportation  is 
always  deficient,  it  is  a  desideratum  to  march  with 
the  smallest  amount  of  baggage,  and  our  men  willing- 
ly leave  their  tents — even  field-officers  preferring  the 
protection  of  their  blankets  and  india-rubber  cloths 
under  the  open  sky,  to  the  trouble  of  unloading  their 
wagon  of  its  camp  equipage.  If  possible,  dry  grass  or 
leaves  form  their  bed,  and,  lying  in  their  greatcoats 
and  upon  their  india-rubber  cloths,  they  can  enjoy 
peaceful  slumber. 

In  marching  through  a  wooded  country,  as  is  our 
own,  it  is  surprising  to  see  with  what  dexterity  a 
mess  can  build  for  themselves  a  shelter  for  the  night. 
On  a  regular  march  the  column  usually  halts  for 
the  night  at  about  five  o'clock  in  the  afternoon, 
which  gives  the  men  ample  time  to  prepare  their  hut 
or  tent,  after  the  following  method:  Two  sticks,  four 
and  a  half  feet  long,  with  a  fork  at  one  end,  arc 
planted  in  the  ground,  a  ridge-pole  placed  in  the 
forks.  A  large  blanket  thrown  over  the  ridge  forms 
a  comfortable  tent,  which  can  be  perfected  in  ton 
minutes;  or  branches  may  bjB  laid  either  side  of  the 
ridge-pole  to  the  ground,  which  would  enclose  the 
area  of  a  tent.  In  summer  it  is  preferable  to  cut 
the  forked  sticks  longer,  and,  leaving  one  side  of 
the  shed  opposite  t<>  the  direction  of  the  wind  open, 
incline  the  branches  only  upon  one  side,  which  will 
give  those  sleeping  under  its  sloping  roof  protection 
from  the  dews  or  lain,  and  also,  to  a  certain  extent. 


48  ENCAMPMENT. 

from  malarial  emanations  wafted  by  the  currents 
of  air  over  the  temporary  resting-place  of  the  army. 

If  there  is  no  cover  for  the  men,  then  they  build 
fires,  and  sleep  around  these — lying  as  so  many  radii 
of  :i  circle,  the  feet  of  the  sleepers  being  nearest 
to  the  fire.  Singular  to  say.  this  kind  of  rough  life 
does  not  bring  with  it  disease,  as  '>ne  would  suppose. 
If  the  men  are  warmly  clad,  they  always  enjoy  more 
health  when  hivouacked  than  when  under  tents;  and 
as  experience  has  taught  our  men  the  advantages 
of  this  life  in  the  summer  months,  they  leave  their 
tents  behind  without  regret,  and  with  them  such  con- 
tagious diseases  as  had  clung  to  the  army  while  they 
remained  in  their  permanent  camp.  Necessity  has 
also  forced  some  of  our  veteran  troops  to  dispense 
with  Jill  shelter;  even  during  the  hitter  cold  of  the  past 
winter,  the  only  cover  which  the  men  had  being  the 
leafless  trees  of  the  forest.  The  army,  in  constant 
motion,  would  lay  down  at  night  by  their  camp-fires, 
and,  after  a  sound  night's  sleep,  our  soldiers  would 
often  find  themselves  in  the  morning  nearly  buried 
in  snow.  They  would  shake  oft*  the  snow,  rekindle 
their  fires,  and  at  least  enjoy  the  satisfaction  of  never 
suffering  from  catarrhal  affections. 

No  troops  should  ever  bivouac  upon  damp,  marshy 
soil,  where  a  single  night's  exposure  in  summer  would 
poison  numbers  with  malaria,  or  in  winter  would 
be  the  fruitful  cause  of  pneumonia  or  rheumatic  affec- 
tions. 

The  site  of  ;i  permanent  camp  should  he  dry.  with 
good  drainage — the  dryness  of  the  soil  being  tested  by 
digging,  to  see  that  a  stratum  of  water  docs  not  imme- 
diately underlie  the  crust.  In  cold,  damp  countries, 
the  material  for  tents  should  be  close,  and,  as  nearly 
as  possible,  water-proof;   and   when   pitched,  a   good 


WARMING    TENTS.  4!> 

ditch  should  bo  dug  around  (lu'in,  with  the  earth 
banked  up  against  the  tent  to  keep  out  the.  cold  and 
rain.  When  troops  in  tho  field  go  into  "winter- 
quarters,  it  is  customary  to  build  for  their  protection 
log-houses,  cabins,  or  huts,  covered  in  with  boards, 
long  segments  of  bark,  or  with  a  fly.  At  times,  deep 
holes  are  excavated,  and  roofed  over  with  planking ; 
a  ditch  around  the  enclosure,  which  should  bo  always 
deeper  than  the  excavation,  and  filled  with  loose 
stones,  will  keep  the  apartment  dry.  In  a  very  cold 
climate  theso  make,  perhaps,  the  warmest  and  most 
comfortable  of  winter-quarters. 

The  method  commonly  adopted  in  our  army  for 
warming  tents,  is  to  construct  a  chimney  at  the  back  of 
the  tent,  of  sticks  built  up  in  pen-form,  well  covered 
with  clay,  and  capped  with  a  flour-barrel — the  open 
portion  in  the  tent  being  formed  by  arranging  two 
rows  of  upright  sticks  three  or  four  inches  apart, 
forming  thi'oe  sides  of  a  square,  the  interval  between 
which  rows  is  filled  with  clay.  Tho  back  of  the  tent 
is  slit,  and  the  edges  secured  closely  to  the  sides  of  the 
chimney,  which  throws  the  fireplace  into  the  tent, 
and  makes  very  comfortable,  warm  quarters. 

An  excellent  modo  of  making  a  tent  comfortable 
in  cold  weather,  is  by  excavating  a  basement  about 
three  feet  deep,  which  will  at  the  same  time  give 
more  room,  and  permit  of  a  stove  or  fireplace  in  the 
centre  of  tho  tent.  The  dirt  from  within  should 
bo  banked  up  against  the  outer  side  of  the  tent,  to 
keep  out  cold  and  moisture.  Communicating  ditches 
should  be  provided, to  facilitate  drainage.  Of  tents, 
tho  circular  offers  tho  best  protection  against  tho 
wind,  is  least  Liable  to  bo  blown  down,  and  is  most 
useful  for  winter. 

Tim    light    shelter-tent    of    the    French    troops,  as 


50  6HELTER-TENT. 

introduced  by  Marshal  Bagoaud,  is  found  most  con- 
venient daring  the  Bummer  months  (or  an  army  in 
tho  field,  and  has  been  generally  introduced  into 
the  Confederate  Bervice  as  the  army  tent.  The  tent 
is  made  of  the  knapsack  of  tho  Boldier,  which, 
instead  of  being  sewed  up,  has  its  sides  buttoned 
together.  When  unbuttoned,  it  is  a  square  piece 
of  cloth.  When  two  or  four  sacks  spread  open  are 
thus  united,  the  centre  supported  by  two  -ticks  three 
feet  long,  and  the  angles  staked  to  the  ground  by 
small  camp-pins,  the  two  or  four  persons  to  whom 
the  sacks  belong,  by  thus  joining  property,  have  a 
tent  that  will  keep  them  from  exposure  to  the  sun, 
and  also  protect  them  from  rain  or  dew.  This  tent  is 
not  more  than  three  feet  high  at  its  ridge.  In  hot 
and  dry  weather,  instead  of  pinning  the  two  sides  to 
the  ground,  one  of  them  can  lie  hung  horizontally  to 
brandies  of  trees,  leaving  one  side  open  for  thorough 
ventilation,  while  tho  horizontal  portion  protects 
tho  sleeper  from  unduo  exposure.  Tho  size  of  this 
tont  can  be  increased  to  any  extent  by  joining  stock, 
as  all  such  sacks  are  of  tho  same  size,  with  buttons 
and  button-holes  arranged  equidistant. 

By  employing  this  excellent  suggestion,  }rou  avoid 
loading  the  shoulders  of  a  soldier,  or  transporting 
tents  for  the  army,  which  is  often  impracticable.  In 
u  few  minutes  after  the  day's  march  has  terminated 
tents  are  pitched,  and  the  camp  assumes  its  regular 
appearance,  without  waiting  for  the  baggage  train. 

Rider's  tent-knapsack  is  made  as  follows:  It  is  com- 
posed of  a  piece  of  gutta-percha  cloth,  five  feet  three 
inches  long  by  three  feet  eight  inches  wide.  Two 
of  the  borders  are  pierced  with  button-holes  for  brass 
studs,  a  third  border  has  a  double  edge,  between 
which  may  be  inserted  and  buttoned  a  second  knap- 


soldier's  bed.  51 

Sack,  while  the  fourth  edge  would  have  the  straps  find 
hackles  necessary  to  elose  the  knapsack.  The  weight 
of  the  gutta-percha  sheet,  when  prepared,  is  throo 
pounds.  The  additional  accoutrements  carried  by  tho 
soldier  arc  two  sticks,  three  feet  eight  inches  long 
and  one  and  a  quarter  thick,  which  may  be  divided  in 
the  middle,  with  the  pieces  securely  attached  to  each 
other  by  a  ferule;  also  a  small  cord.  When  used  as 
a  knapsack,  the  clothing  is  packed  in  a  bag,  and  the 
gutta-percha  is  folded  around  it,  lapping  at  the  ends, 
so  that  tho  clothing  is  protected  by  two  or  three 
thicknesses  of  gutta-percha.  Four  knapsacks  button- 
ed together  will  form  a  sheet  ten  feet  six  inches  long 
by  seven  feet  four  inches  wide,  and  when  pitched  on  a 
rope  three  feet  four  inches  above  the  ground,  covers  an 
area  of  six  feet  six  inches  wido  by  seven  feet  four 
inches  long,  which  will  accommodate  five  men,  and 
may  be  made  to  givo  shelter  to  seven.  The  sheet  can 
also  be  used  upon  the  ground,  and  is  a  great  protection 
against  dampness. 

In  a  regular  camp  the  soldier's  bed  should  never  bo 
directly  upon  the  ground — as  the  earth  always  con- 
tains moisture  enough  to  permeate  the  clothing,  and 
rheumatism,  pleurisy,  pneumonia,  and  such  kindred 
affections,  may  be  the  consequence.  If  beds  can  not  be 
obtained,  branches  or  dried  leaves  or  straw  should  be 
used,  upon  which  the  blankets  are  spread.  An  ele- 
vated bed  can  be  made  by  supporting  rails  upon  four 
forked  sticks  with  riding  pieces;  leaves  or  straw  put 
upon  these,  and  covered  with  a  blanket,  will  make  an 
excollenl  couch.  This  answers  the  double  purpose  of 
koeping  the  body  from  the  damp  ground  and  of  e  leva  t- 
bag  it  into  a  layer  of  purer  air.  When  tin1  tent  is 
ailed,  as  is  usually  tho  case,  the  exhaled  air,  loaded 
with  carbonic  acid  and  other  impurities,  settles  to  the 


'<2  soldier's  bed. 

ground.  Unless  free  circulation  (-fair  i>  permitted  in 
the  tents,  persons  Bleeping  npon  the  ground  would  be 
continually  inhaling  this  poisoned  atmosphere,  to  their 

injury. 

The  soldier's  bed  should  be  always  dry.  All  moist, 
decomposing  materials,  such  as  green  grass  or  leaves, 
collected  in  a  tent  lor  a  permanent  bed,  arc  more  in- 
jurious than  sleepingnpon  the  soil,  owing  to  the  gases 
escaping  from  their  decomposition.  True  economy 
would  dictate  a  painted  cloth  for  the  floor  of  the  tent, 
as  this  would  prevent  the  exhalation  of  moisture  from 
tho  earth's  surface,  is  convenient,  always  ready,  and 
less  expensive  than  straw.  It  can  he  cleaned  every 
(lay  with  little  trouble,  without  cost,  and  requires  to 
be  freshly  painted  only  once  a  year. 

When  straw  or  hay  is  used  for  bedding,  it,  should 
be  renewed  as  frequently  as  possible,  and  the  straw 
should  be  turned,  well  beaten,  and  thoroughly  aired 
daily,  with  exposure  to  the  sun  when  possible.  In  the 
French  camp,  straw  is  given  out  every  fifteen  days j 
in  our  army  regulations  twelve  pounds  is  allowed  per 
month  in  barracks. 

As  a  soldier  always  sleeps  in  his  clothes,  if  he  has  a 
thick  bed  of  dry  straw  to  lie  upon,  ho  can  cover  him- 
self with  his  blanket;  but  if  otherwise,  he  should  lie 
on  his  blanket,  well  doubled,  to  protect  him  from  the 
damp  soil,  and  cover  with  his  overcoat.  If  he  has  an 
india-rubber  cloth,  lie  should  always  lio  upon  it,  as  the 
very  best  use  he  can  make  of  it  to  protect  himself  from 
disease.  It  is  an  oxcellcnt  substitute  for  straw  in 
field  life.  morO  cleanly,  and  protects  bettor  from 
dampness;  it  is  always  at  hand,  and  always  read}'  for 
use.  Sheepskins  were  tried  by  the  French  as  a  substi- 
tute for  straw.  They  were  found  to  attract  moisture 
and  propagate  vermin,  and  were  therefore  rejected. 


CLEANLINESS    OF    A    CAMP.  53 

As  the  tout  is  always  too  .small  for  the  number 
which  occupy  it,  the  inmates  should  sleep  with  their 
heads  as  far  as  possible  from  each  other.  In  the  cir- 
cular tent,  they  should  sleep  with  their  feet  toward 
the  vortical  axis  and  their  heads  around  the  periphery, 
so  as  to  increase  to  the  utmost  their  respective  areas 
for  respiration.  After  reveille  the  tents  should  bo 
opened,  sides  thoroughly  beaten,  straw  turned,  and 
exposed  for  several  hours. 

Extreme  cleanliness  should  prevail  within  and  with- 
out the  tent.  In  an  encampment  the  tents  should 
never  be  crowded,  but  ample  space  should  be  left 
around  each  tent  for  changing  its  position  at  least 
every  week,  so  as  to  purify  the  soil  infected  by  habi- 
tation. The  earth  floor  of  a  tent  attracts  and  ab' 
sorbs  impurities  which,  unless  changed,  would  soon 
render  it  a  source  of  disease.  Permanence  of  camps 
rapidly  induces  infection.  This  frequent  changing  of 
tents  gives,  to  be  sure,  additional  trouble  to  the 
officers  and  men  who  may  not  appreciate  its  advan- 
tages, but  this  is  more  than  counterbalanced  by  the 
health  and  efficiency  of  the  command.  All  the 
garbago  of  the  camp  should  be  thrown  at  a  distance 
from  the  tents,  and  should  be  buried  every  evening. 

The  privies  or  sinks  for  the  men  are  ditches, 
from  three  to  five  feet  deep  and  three  feet  broad, 
Screened  from  view  by  branches  stuck  in  the  earth. 
A  crotched  stick  is  driven  into  the  ground  at  each  end, 
and  a  pole  laid  across  to  serve  as  a  seat.  These  sinks 
should  be  dug  narrow  and  deep,  so  as  to  leave  as  littlo 
Bpace  a-^  possible  for  evaporation.  Usually  three 
sinks  are  dug  for  each  regiment,  viz:  ono  for  the 
men,  one  for  the  use  of  line  officers,  and  one  tor 
the  field  and  stall'  officers.  The  common  laws  of 
hygiene   insist  that    these    bo  prepared    immediately 


54  CLEANLINESS   OF   A   CAMP. 

upon  the  establishment  of  an  encampment,  and  that 
the  men  be  compelled  to  use  them  under  ;i  penalty. 
The  want  of  these,  and  the  negligence  in  insisting  upon 
their  use.  may  be  considered  one  of  the  chief  causes 

of  the  fearful  amount  of  sickness  which  existed  in  the 
summer  of  1861  in  our  armies.  Gentlemen  who 
composed  our  volunteer  regiments  would  not  obey 

the  orders  to  use  these  sinks,  and  as  the  offieers  did  not 
insist  upon  what  the  men  objected  to  as  unnecessarily 
troublesome,  the  result  was  that,  with  but  few  excep- 
tions, our  regimental  camps  were  accumulations  of 
tilth  of  every  description,  which  could  be  detected  at 
a  distance  while  approaching  them.  It  was  not  sur- 
prising that  disease  and  death  followed  in  the 
wake  of  such  inditferenco  to  all  laws  of  decency  and 
hygiene. 

As  soon  as  a  camp  is  established,  the  quartermasters 
of  regiments  locate  the  sinks,  and  fatigue  squads  pre- 
pare them  for  use.  A  patrol  guard  is  then  established, 
whose  duty  it  is  to  see  that  the  grounds  about  the 
camp  are  not  defiled.  All  delinquents  are  punished 
with  fatigue  duty  in  policing  the  camp  under  the 
guidance  of  the  officer  of  the  day,  who  always  has 
under  his  charge  a  Dumber  of  unruly  men,  who  pay  the 
penalty  of  infringing  military  rules  by  devoting  all  of 
their  spare  time  to  the  cleansing  of  the  camp,  in  bury- 
ing offal,  and  in  digging  new  sinks  when  those  in  use 
have  been  sufficiently  filled.  Under  the  feeling  of 
responsibility  which  is  now  felt  in  the  army,  and 
the  more  stringent  reports  of  brigade  and  division 
inspectors,  a  much  more  wholesome  condition  exists 
in  enforcing  such  sanitary  regulations  of  cleanliness, 
etc.,  as  the  massing  of  men  absolutely  require. 

The  privies  should  be  placed  at  least  one  hundred 
yards  from   the    tents,  and  in    an    opposite  direction 


EMPLOYMENT   IN    CAMP.  55 

to  the  wind  currents,  so  that  offensive  odors  will 
be  blown  away.  Where  proximity  to  the  water 
permits,  they  should  be  established  over  the  running 
stream.  This  will  remove  a  great  and  common 
source  of  infection,  which  is  very  difficult  to  coun- 
teract. The  slaughter-pens  should  also  be  placed  at  a 
similar  distance.  Every  evening  the  offal  of  the  day 
should  be  covered  with  three  or  four  inches  of  earth, 
or  :i  sufficient  layer  to  prevent  any  smell  arising  from 
the  day's  deposit.  When  the  trench  is  two-thirds 
full  it  should  be  closed,  and  another  of  similar  dimen- 
sions opened. 

In  permanent  camps,  dead  animals,  horse-dung, 
and  all  animal  refuse,  should  be  buried,  otherwise 
the  stench  from  them  would  be  very  injurious  to 
the  health  of  the  troops.  But  as,  notwithstanding  the 
utmost  eai-e,  in  the  most  salubrious  situations,  diseases 
will  in  time  show  themselves — from  the  inevitable  ac- 
cumulation of  poisonous  materials,  resulting  from  the 
growing  infection  of  the  soil,  with  its  poisonous  emana- 
tions, from  the  prolonged  sojourn  of  a  large  number 
of  men  and  animals — the  camp,  unless  occupying  a 
position  of  marked  military  importance,  should  be 
changed  for  a  new  situation  at  some  convenient 
distance. 

As  the  daily  drills  do  not  suffice  to  develop  the 
physical  organization  of  the  soldier,  he  might  be 
usefully  employed  upon  public  works,  which  may 
revert  to  his  individual  benefit — as  the  erection  of 
batteries,  the  making  of  military  roads,  draining  the 
sites  of  camps,  etc.  For  months  the  roads  in  the 
vicinity  of  .Manassas,  where  the  Army  of  the  Potomac 
were  stationed,  were  nearly  impassable,  and  transpor- 
tation was  so  exceedingly  difficult,  that  the  army 
suffered    severely  for  proper  food.     Had    the   troops 


56  AMUSEMENTS    IN    CAMP. 

boen  ordered  to  work  the  roads  instead  of  loitering  for 
months  in  camp,  the  service  would  bsve  been  mate- 
rially advanced. 

The  same  want  of  forethought  occurred  around 
Charleston,  where  a  large  army  was  kept  idle  for 
months,  while  the  laboring  agricultural  population 
were  taken  from  their  farms  when  they  could  ho 
least  spared,  to  erect  works  which  the  soldiers  would 
gladly  have  done,  the  more  especially  if  they  could 
have  received  the  extra  pay  allowed  to  these  laborers. 
The  provisions  would  have  heen  more  abundant,  and 
soldiers  could  have  been  taught  to  labor,  and  by 
degrees  inured  to  hard  work,  with  all  of  its  advan- 
tages, if  they  had  heen  put  in  the  trenches.  In  the 
Army  of  Virginia  the  soldiers  were  found  not  only 
always  ready  but  willing  to  engage  in  such  work  as 
was  required;  and  often,  when  ennui  had  taken  pos- 
session of  the  camp,  and  homesickness  threatened 
to  break  out  as  an  epidemic,  an  order  to  erect  works 
was  always  hailed  with  pleasure,  and  in  twenty-four 
hours  the  entire  camp  would  resume  its  accustomed 
gayety.  Works  were  erected  which  we  never  cx- 
pocted  to  use,  simply  to  keep  the  men  employed,  and 
make  them  contented  and  happy. 

To  enliven  and  relieve  the  toil  and  tedium  of  camp 
life,  amusements  are  a  very  necessary  portion  of  tho 
daj'-'s  duties;  and  it  is  found  that  lively  music  from 
the  military  bands  every  afternoon,  will  elato  tho 
men  and  remove  monotony.  Singing  and  music 
should  be  a  portion  of  tho  military  education,  as  offer- 
ing an  agreeable  modo  of  passing  the  many  idlo 
hours  of  camp  lite  which  usually  hang  so  heavily 
upon  the  soldier.  Temporary  gymnasia  might  be 
established,  and  gymnastic  exercises  should  be  en- 
couraged as  conducive  to  hoalth,  strength,  agility,  and 
address. 


AMUSEMFNTS    IN    CAMP.  57 

The  manly  play  of  ball,  with  its  invigorating  exer- 
cise, is  the  common  amusement  in  a  Confederate 
camp.  In  winter  this  gives  place  to  mock-battles 
with  snowballs,  when  regiments  and  brigades  arc 
marshalled  against  each  other  in  amicable  array,  and 
take  as  much  pride  in  attacking  and  in  repelling 
assaults,  and  taking  prisoners,  as  they  have  felt  on 
the  battle-field  in  taking  and  holding  an  enemy's 
position.  Besides  ball-playing,  soldiers  in  camp 
amuse  themselves  with  rolling  ten-pins,  shooting 
marbles,  throwing  quoits,  racing,  wrestling — any  of 
which  are  preferable  to  card-playing,  which,  in  camp, 
is  inseparable  from  gambling.  Cock-fighting  is  also 
an  amusement  of  permanent  camps,  both  officers  and 
men  in  our  volunteer  army  participating  in  this  sport. 
Animal  pets  are  very  seldom  met  with  in  the  army. 
As  our  troops  find  difficulty  in  supplying  themselves 
with  sufficient  food,  foraging  for  animals  can  not  be 
thought  of.  This  feeling  of  sympathy  with  the  brute 
creation  has  been  crushed  by  the  hardships  which 
have  destroyed  thousands  of  noble  horses,  the  private 
property  of  officers  and  men,  who  have  lost  their 
favorite  blooded  pets  from  the  gradual  starvation  at- 
tendant upon  a  permanent  deficiency  of  food. 

In  the  summer  of  1850,  during  the  Italian  cam- 
paign, I  was  at  Milan  when  a  largo  body  of  French 
troops,  returning  from  the  bloody  field  of  Solferino, 
arrived.  In  a  few  minutes  their  shelter-tents  were 
pitched,  under  tho  shade  of  tho  trees  on  the-  broad 
boulevard  which  surrounds  the  city,  and  tho  soldiers 
were  allowed  to  follow  the  bent  of  their  own  in- 
clination. Card- playing,  dominoes,  fortune-telling, 
wrestling,  and  dancing  to  the  discordant  tunes  of  a 
hand-organ,  or  the  sharp  notes  of  an  accordeon,  ap- 
peared to  be  the  order  of  the  day. 


OS  AMUSEMENTS   IN    CAMP. 

1'  ts  in  various  forms  were  commonly  found  among 
the  troopsj  and  those  were  guarded  with  Bcrupuloua 
care.  Many  appeared  to  be  adopted  by  the  regiment 
as  comrades,  who  have  been  associated  together 
through  many  a  hard-fought  field  and  toilsome 
march.  In  the  military  hospitals  of  -Milan — which 
were  filled  with  the  wounded,  from  ita  very  near 
proximity  to  the  battle-field  and  railroad  facilities 
for  transportation — it  was  not  unusual  to  see  a  sol- 
dier, nearly  exhausted  from  the  tedious  dressing  of  a 
frightful  wound,  when  he  had  passed  from  the  hands 
of  the  surgeon,  take  from  his  bosom  a  little  sparrow, 
and  from  the  cheerful  chirp  of  this  little  bird  appear 
to  derive  much  consolation. 

Not  the  least  attractive  incident  connected  with 
the  triumphal  march  of  Napoleon's  Italian  army 
through  Paris,  in  August,  1859,  was  the  pets  accom- 
panying these  brave  heroes.  Here  would  be  seen  a 
goat,  evidently  proud  of  its  position,  marching  with 
military  step  at  the  head  of  a  column  of  ferocious 
Zouaves — going  through  the  halt  and  advance  by 
word  of  command,  looking  neither  to  the  right  or  left, 
as  if  the  success  of  the  day  depended  upon  its  mili- 
tary deportment.  Here,  a  regimental  dog  would 
show  the  pleasure  with  which  he  participated  in  this 
great  occasion,  while  tho  caresses  of  the  company, 
and  the  pleasant  faces  with  which  his  presence  would 
always  be  recognized,  show  the  appreciation  of  his 
companionship.  These  little  incidents  arc  introduced 
to  show  the  longing  of  all  men  for  objects  of  affection, 
and  also  how  many  a  tedious  and  otherwise,  unbear- 
able hour  in  camp  life  is  pleasantly  spent  in  fostering 
those  fine  feelings  of  the  human  heart  which  keep 
soldiers,  accustomed  to  blood,  from  becoming  de- 
graded and  brutal. 


CHAPTER    II. 

Hospitals,  Regimental  and  Ceneral —  Hospital  Tents,  with 
Equipment  —  Number  ok  Attendants  allowed — Duties  of 
Surgeon  in  charge  or  a  General  Hospital  —  op  Division 
Surgeon —  Assistant  Surgeon— Apothecary  —  Hospital  Stew- 
ard —  Ward  -Master —  Nurses  —  Matrons  —  Laundresses  — 
Tatients  —  Cleansing  op  Hospitals  —  Care  necessary  in  pre- 
venting Infection  —  Value  op  Fumigation  —  Female  Attend- 
ants—  Hospital  Diet,  etc. 

The  accommodations  for  the  sick  form  a  very  im- 
portant department  in  the  economy  of  an  army,  and, 
as  a  rule,  are  never  sufficiently  ample.  With  every 
body  of  troops  in  the  field  there  arc  two  kinds  of 
hospitals — the  regimental  and  the  general.  With 
regular  armies  there  should  always  ho  a  third — tho 
convalescent  hospital — situated  in  some  salubrious, 
rural  location,  where  convalescents,  b}-  inhaling  pure 
air,  and  enjoying  the  pleasures  of  country  life,  can 
rapidly  rebuild  their  shattered  constittitions. 

For  the  army  in  Virginia,  during  the  summer  and 
autumn  of  1861,  convalescent  hospitals  were  estab- 
lished at  points  well  adapted  for  the  purpose,  and 
were  of  essential  benefit.  Tho  Virginia  springs  are 
known  to  all  tho  world  ;  at  such  places  of  resort 
every  convenience  exists  for  accommodating  largo 
numbers  of  visitors.  At  some  of  these  watering- 
places  tho  hotels  and  numerous  cottages  were  con- 
verted into  extensive  hospitals,  where  convalescents 
from  measles  and  typhoid  fever  could  use  the  min- 
eral waters,  enjoy  the  fine  scenery,  and  recruit  rap- 
idly. 


60 


REGIMENTAL    HOSPITAL. 


The  regimental  HOSPITAL  is  usually  under  tents 
■when  in  the  field,  if  a  suitable  building  in  the  im- 
mediate vicinity  of  the  encampment  can  not  bo 
obtained.  According  t<>  army  regulations,  the  tents 
used  as  hospitals  in  the  Confederate  service  should  he 
fourteen  feet  in  Length,  fifteen  feet  wide,  and  eleven 
feet  high  in  the  centre,  with  a  wall  four  and  a  half 
feet,  and  a  "fly"  of  appropriate  size.  The  ridge-pole  is 
made  in  two  sections,  measuring  fourteen  feet  when 
joined.  On  one  end  of  the  tent  is  a  lapel,  which 
admits  of  two  or  more  tents  being  joined  or  thrown 
into  one.  with  a  continuous  covering  or  roof;  such 
a  tent  accommodates,  comfortably,  from  eight  to  ten 
patients.  The  following  is  the  allowance  of  tents  for 
the  sick,  their  attendants,  and  hospital  supplies — being 
accommodation  for  ten  percent,  of  the  command  : 


COMMANDS. 

HOSPITAL  TEKTS. 

SIBLEY   TENTS. 

COMMON   TENTS. 

For  three  companies.. . 
por  five  companies  .  •  • 
Fur  seven  oompanies. . 
Fur  ten  companies 

1 

2 
2 
3 

1 
1 
1 
I 
1 

1 
1 
1 
1 
1 

Owing  to  tbo  sparcity  of  manufactories  and  tho 
stringency  of  the  blockade,  tents  have  always  been 
scarce  in  our  army  from  the  very  commencement 
of  our  troubles.  At  sundry  times  we  have  been  com- 
pelled, in  our  sudden  change  of  position,  and  from  in- 
sufficient transportation,  to  destroy  our  tout  equipage 
to  prevent  their  falling  into  the  hands  of  the  enemy. 
Having  no  reserve  supply  from  which  to  draw,  our 
army  has,  at  such  times,  not  only  been  compelled  to 
live  without  tents,  but  tho  hospital  supply  has  been 
materially  curtailed.     Rarely   lnis  a   regiment  more 


REGIMENTAL    HOSPITAL.  61 

thai)  two  walled  tents  to  accommodate  its  sick,  and 
much  more  frequently  but  one  walled  tent  and  one 
fly.  On  this  account,  only  those  eases  which  promise 
to  ho  transient  indispositions  or  acute  diseases  arc 
retained  for  treatment  in  the  regimental  hospitals. 
They  must  always  he  considered  hut  temporary 
structures,  to  he  moved  with  the  army,  and  to  bo 
broken  up  at  an  hour's  notice.  They  should  never, 
therefore,  he  encumbered  with  chronic  cases,  nor 
should  thoy  ever  be  permitted  to  be  crowded.  As 
soon  as  a  caso  threatens  to  remain  longer  than  a 
few  days  in  hospital,  it  should  be  transferred  to  tho 
general  hospital  for  treatment. 

To  ensure  a  comfortable  abode  for  tho  sick,  tho 
site  of  the  regimental  hospital  should  be  selected  with 
much  cai-e — the  dryest  spot  in  the  camp  should  bo 
chosen,  and  the  tent  well  ditched,  to  give  thorough 
drainage.  The  floor  of  the  tent  should  be  carpeted 
with  oil  floor-cloth  or  painted  canvas,  which  will  pro- 
tect the  sick  from  the  emanations  from  the  soil,  and 
will  prevent  the  soil  from  imbibing  animal  effluvia, 
at  the  same  time  keeping  out  all  moisture,  which  is  so 
deleterious  to  those  lying  upon  the  ground.  This 
painted  cloth  strictly  belongs  to  tho  hospital  tent, 
and,  as  an  essential  part,  should  not  be  overlooked. 
A  certain  number  of  bedsacks  also  belong  to  tho  hospi- 
tal. When  these  are  filled  with  straw,  they  make 
a  much  more  comfortable  bed  than  straw  thrown 
in  heaps,  which  is  the  common  modo  of  treating 
the  sick  in  the  field.  There  is  much  comfort  in 
appearances,  and  these  beds  add  much  to  the  neat- 
ness as  well  as  cleanliness  of  the  tent.  The  beds  are 
arranged  on  either  side  of  the  tent,  with  the  beads 
turned  toward  the  wall.  Could  the  beds  be  elevated 
upon  boards  tor  six  or  twelve  inches,  they  would  place 


62  HOSPITAL    ATTENDANTS. 

the  sick  in  a  purer  atmosphere  thai)  when  lying  OD  the 

flour,  where  the  heavy,  deleterious  gases  of  expiration 

Collect.      In    good   weather,  ventilation   of  these    tents 
should  always  lie  insisted  upon. 

The  straw  should  be  changed  as  often  as  possible, 
oven  twice  a  week,  if  it  can  be  procured;  while,  if  the 
patient  can  get  up,  the  bed  should  be  well  beaten  and 

thoroughly  aired  daily. 

It  often  occurred,  in  the  medical  experience  of 
the  Confederate  service,  that  straw  could  not  bo 
procured — the  inmates  of  the  regimental  hospital  being 
compelled  to  lie  directly  upon  the  ground,  which  was. 
at  times,  damp,  and  even  muddy,  with  no  india-rubber 
cloths  to  protect  them,  and  often  without  blankets 
to  cover  them.  The  suffering  from  the  want  of  these 
necessary  articles  has  been  very  great,  and  yet  the 
men,  in  the  beginning  of  the  war,  would  prefer  remain- 
ing in  camp  when  sick,  rather  than  enter  the  general 
hospitals,  against  which  they  had  the  strongest 
antipathy. 

Personal  cleanliness  of  the  patient  is  as  important  <is 
that  of  the  tent.  Ablutions  should  bo  freely  used, 
although  it  may  not  be  possible  frequently  to  change 
the  underclothing.  Whenever  the  condition  of  the 
patients  permit,  the  tent  should  be  moved  once  a 
week,  if  it  be  only  a  few  yards  from  its  former  position, 
so  as  to  enclose  a  fresh  piece  of  soil  not  contaminated 
with  animal  exhalations.      Tins  change  of  location   IS 

particularly  required  whenever  any  of  the  low  grades 
of  contagious  diseases  appear  within  its  walls,  or  cases 

under  treatment  take  <>n  an  asthenic  character. 

The  hospital  i8  allowed  a  certain  number  of  attend" 
ants,  to  attend  to  the  coiumis.-aiy  and    medical  duties 

of  the  establishment    Bach  company  has  one  steward, 

one  nurse,  and  one  cook  ;   for  each  additional  company, 


HOSPITAL   ATTENDANTS.  63 

one  nurse  is  added  ;  and,  for  commands  of  over  five 
companies,  one  additional  cook,  if  required.  As  a  rule, 
one  nurse  is  taken  from  the  ranks  for  every  fen 
men  sick  in  regimental  hospital.  When  there  are  but 
few  cases  under  treatment,  the  supernumerary  nurses 
and  cooks  are  returned  to  the  ranks.  The  surgeon 
is  general  superintendent  of  the  hospital.  Under 
his  direction  the  steward,  who,  in  the  Provisional 
Army  of  the  Confederacy,  is  usually  a  physician  taken 
from  the  ranks,  takes  care  of  the  hospital  stores 
and  supplies,  and  sees  that  the  nurses  and  cooks 
perform  properly  their  respective  duties,  and  acts  as 
medical  dispenser  and  apothecary  to  the  regimental 
hospital.  If  intelligent,  he  can  readily  be  entrusted 
with  prescribing  for  mild  cases  of  disease,  and  thus 
relieve  the  surgeon  of  much  trouble. 

Not  the  least  important  personage  in  the  hospital 
organization  is  the  sentinel  who  guards  the  door,  and 
sees  that  neither  ingress  nor  egress  is  permitted, 
except  upon  orders  from  the  surgeon.  It  is  only  in  this 
way  that  patients  can  be  prevented  from  committing 
imprudences  which  may  cost  them  their  lives.  This 
guard  should  be  constantly  furnished  to  the  hospital, 
and  the  surgeon  is  to  signify  to  the  commanding  officer 
ol  t lie  regiment  the  particular  orders  which  he  wishes 
to  »be  given  to  the  non-commissioned  officer  command- 
ing it,  and  to  the  sentries. 

Those  treated  in  a  tent  hospital  always  convalesce 
much  more  rapidly  than  those  collected  together  in  a 
large  hospital  building,  where,  in  proportion  to  the 
magnitude  of  the  establishment  and  number  of  pa- 
tients, we  flttd  the  convalescence  of  the  sick  pro- 
longed, the  number  of  deaths  increased,  and  the 
germs  of  contagious  diseases  developed.  In  concen- 
trating  a   number  of  sick    under  one  roof,  although 


64  GENERAL   HOSPITALS. 

many  facilities  for  troating  thora  are  gained,  yet  the 
laws  of  hygiene  will  be,  to  a  certain  extent,  ana  void* 
ably  violated.  Yet,  Prom  the  very  transionl  nature 
of  regimental  hospitals,  more  permanent  institutions 

for  the  siek  must  necessarily  l>e  established. 

General  hospitals  are  usually  located  in  some  town 
or  city  contiguous  to  tho  army;  or,  should  such 
locations  he  too  distant,  without  facilities  of  trans- 
portation, buildings  are  taken  possession  of,  or  erect- 
ed, near  the  military  position,  to  be  used  as  a  general 
hospital.  The  organization  of  this,  with  its  surgical 
staff,  its  Stewards,  ward-masters,  and  nurses,  is  upon 
a  much   larger  scale  than   in   tho  regimental   hospital. 

Early  in  tho  war,  when  our  large  and  increasing 
army  was  undergoing  acclimation,  with  thousands  of 
sick,  extensive  general  hospitals  were  required  for  im- 
mediate use,  with  no  time  allowed  for  the  erection  of 
proper  buildings.  The  medical  department  was  com- 
pelled to  use  factories,  storehouses,  hotels,  college  S, 
or  such  large  buildings  as  could  be  found  contiguous 
to  the  position  of  our  armies.  In  Richmond  alone, 
numerous  buildings,  to  accommodate  nearly  thirty 
thousand  patients,  were  fitted  up  as  hospitals.  Tho 
same  course  was  pursued  elsewhere.  At  the  present 
time,  however,  such  temporary  hospitals  have,  to  a 
great  extent,  been  replaced  by  newly- erected  build- 
ings, specially  arranged  for  the  convenience  of  the 
sick.  The  general  plan  of  organization  which  ap- 
pears to  meet  with  most  approval,  allows  of  the  con- 
centration of  a  large  number  of  sick  under  ono 
supervision — the  general  hospitals  recently  construct- 
ed oumbering  from  ono  thousand  to  five  thousand 
beds.  The  advantages  accruing  from  this  arrange- 
ment are  the  greater  facilities  for  treating  the  sick, 
an   increase   of  comforts,   with   the  groat  advantage 


GENERAL   HOSPITALS.  65 

of  sustaining  a  rigid  military  discipline,  the  greater 
readiness  with  which  discharged  soldiers  arc  returned 
to  dut}',  a  more  perfect  organization,  with  a  more 
judicious  division  of  labor,  without  increasing  oom- 
monsurately  the  expenses  of  the  institution,  or  re- 
quiring .pro  rata  so  many  officers;  and  last,  but  not 
least,  of  rather  diminishing  the  mortuary  list  or  per* 
centage  of  deaths. 

The  general  plan  upon  which  an  institution  of  this 
kind  is  now  established,  is  by  erecting  a  number  of 
one-story  houses,  about  eighty  feet  long  by  thirty  feet 
wide,  well  ventilated  by  means  of  slatted  cupolas. 
Such  buildings  will  each  accommodate  comfortably 
from  ]'<»rty  to  titty  patients  and  arc  multiplied  so  as 
to  accommodate  from  one  thousand  to  five  thousand 
patients.  The  concentration  of  so  many  buildings 
forms  a  village,  with  regularly  laid  out  streets,  those 
running  in  one  direction  being  one  hundred  feet  wide, 
while  the  cross  streets  are  fifty  feet  in  width.  Each 
house  being  surrounded  by  streets,  ensures  thorough 
ventilation,  and  prevents  over-crowding.  In  such  a 
general  hospital  there  are  many  divisions,  each  com- 
prising about  five  hundred  beds,  and  each  being  a 
perfect  hospital  within  itself,  with  all  offices  necessary 
for  successfully  carrying  on  such  an  establishment, 
viz:  kitchens,  laundries,  mess-rooms,  baggage-room, 
linen-room,  store-room,  and  guard-room.  For  the 
general  QSO  of  all  t  he  divisions,  are  a  bakery;  a  guard- 
house or  prison  for  enforcing  obedience ;  a  chapel,  in 
which  service  is  daily  held,  bath-house,  with  hot, 
st. ■am,  cold,  shower,  and  plunge  baths;  operating 
room,  with  dead-house;    &fficesaud  houses  for  officers 

and   employees;   stables,  and  privies —the   latter  being 
distinct    buildings  for  privates,  non-commissioned  offi- 
cers, officers,  and  matrons. 
F 


60  DUTIES    OF    STJnOEON    IN    CHAROE. 

Ordinarily,  the  following  hospital  attendants  are 
allowed:  :i  hospital  Bteward,  acting  as  mess  steward; 
a  hospital  Bteward,  acting  as  apothecary;  r  ward- 
master  for  ovory  one  hundred  patients;  two  chief 
matrons;  two  assistant  matrons;  two  ward  matrons 
to  each  one  hundred  patients :  one  nurse  t<>  every  ten 
patients  —  but  should  this  number  be  found  not  suffi- 
cient, the  government  allows  the  employment  of  as 
many  as  are  necessary  for  the  careful  nursing  of  the 
sick;  a  laundress  for  every  twenty  patients,  and  a 
cook  for  every  thirty.  In  the  Large  general  hospitals 
each  division  of  the  hospital  is  presided  over  by  a 
surgeon,  who  has  a  number  of  assistant  Burgeons 
under  him — one  t<>  every  seventy  patients.  Bosides 
the  number  of  employees  enumerated  above,  there  is 
a  steward,  who  looks  after  the  servants;  a  baggage- 
master,  and  an  apothecary's  clerk;  and  the  surgeon, 
who  is  in  charge  of  the  entire  establishment,  is  al- 
lowed one  or  more  clerks  for  office  duty.  A  military 
guard  completes  tin'  Btaff  of  a  general  hospital. 

The  following  are  the  duties  assigned  to  each  of 
these  officers,  and  for  the  proper  performance  of 
which  he  is  held  Btrictly  responsible  by  the  surgeon, 
who  is  the  administrating  officer  in  charge  of  the 
institution. 

The  surgeon-in-chief,  who  is  in  charge  of  a  largo 
general  hospital,  is  the  responsible  head  of  such  an 
institution,  and  is  constituted  commander  of  such  a 

pOSt.  It  is  his  duly  to  define  the  duties  of  all  otlieers 
attached  to  the  instit  at  ion,  and  see  that  all  of  tho 
regulations  of  the  hospital  are  rigidly  enforced,     lie 

receives   and    enforces   all    Official  order.-,,  approves   all 

requisitions,  endorses  all  certificates  for  furloughs  or 
discharges  given  by  his  subordinate  medical  officers, 
takes  charge  of  the  hospital  fund   and  attends  to  its 


DUTIES    OF    DIVISION    SURGEONS.  67 

judicious  disbursement,  and  keeps  up  a  continued  sur- 
veillance over  all  depart  incuts  of  the  establishment, 
inspecting  at  8UOh  irregular  times  when  he  may  bo 
least  looked  for.  His  time  is  so  absorbed  in  adminis- 
tering the  affairs  of  the  hospital,  examining  books, 
etc.,  that  he  can  pay.but  little  attention  to  the  special 
care  of  the  sick;  and  except  in  the  capacity  of  a  con- 
sulting and  operating  surgeon,  and  president  of  the 
examining  board,  composed  of  bis  division  surgeons 
and  himself,  leaves  the  treatment  of  the  patients  to 
bis  division  surgeons  and  bis  staff  of  assistants. 

The  division  surgeon,  who  has  charge  of  one  of  the 
divisions  of  the  general  hospital,  is  held  responsible 
by  the  chief  surgeon  for  the  proper  enforcement  of 
all  the  rules  and  regulations  of  the  hospital  in  his  re- 
spective division,  obeying  all  orders  emanating  from 
bis  chief.  He  inspects  every  department  of  his  divis- 
ion daily,  sees  that  all  employees  attend  to  their  re- 
spective duties,  and  renders  a  daily  morning  report  to 
tbe  chief  surgeon,  with  a  copy  of  the  daily  register 
for  his  division,  lie  appoints  a  medical  officer  of  the 
day  from  bis  staff  of  assistants,  whose  duty  it  is  to 
attend  to  all  urgent  calls  of  tbe  sick  in  the  division, 
during  the  twenty-four  hours  that  he  is  on  guard. 
He  grants  permits  to  patients  to  leave  the  hospital; 
approves  requisitions  of  the  hospital  steward;  makes 
out  hospital  pay-rolls,  and  a  monthly  report  of 
sick  and  wounded  in  bis  division;  keeps  copies  of  all 
requisitions,  quarterly  reports,  and  also  copies  of  all 
orders  and  lottors;  and  filos  all  applications  for  fur- 
lough, detail,  transfer,  and  discharge,  for  the  action  of 
xamining  board.  Although  he  usually  takes  no 
ward  himself,  be  visits  daily  all  of  the  serious  cases  in 
bis  division,  accompanied  by  the  assistant  in  charge 
of  Buch  patients,  and,  with  the  chief   Burgeon,   per- 


68 


PfTIKS    or    ASSISTANT    SURGEONS. 


forms  must  of  the  operations  required  in  his  division. 
The  division  surgeons,  with  tin-  chief  surgeon  as  pr< 
ident,  constitute  a  board  of  examiners,  whose  duty  it 
is  to  investigate  tin  eases  of  all  applicants  for  trans- 
fer, detail,  furlough,  or  discharge. 

itant  surgeons  are  the  general  practitioners  of 
the  hospital,  and  are  expected  to  assist  the  chiof  sur- 
geon and  division  surgeon  in  enforcing  rigidly  the 
rules  of  the  hospital,  obeying  all  orders  emanating 
from  their  division  surgeon.  It  is  their  duty  to  visit 
their  patients  at  least  twice  daily,  and  as  much  often- 
er  as  the  serious  charactor  of  cases  may  require. 
They  must  write  each  proscription  in  lull,  including 
diet,  iii  the  proscription  and  diet  hook,  giving  the 
name  of  tin-  patient,  and  number  of  his  lied  and  ward 
in  every  ease,  ami  will  see  that  their  directions  are 
strictly  carried  out.  in  prescribing  alcoholic  stimuli 
of  any  kind,  they  will  specify  the  quantity  which 
each  patient  should  receive,  with  directions  in  full  for 
its  administration.  In  prescribing  it  for  themselves 
or  any  hospital  attendant,  they  must  certify  that  it  is 
for  medicinal  purposes,  and  that  it  is  necessary  for 
the  treatment  of  the  ease  for  which  it  is  prescribed". 
They  wdll  report  daily,  by  eleven  o'clock,  to  their 
division  Burgeon,  all  deaths,  desertions,  convalescents 
lit  for  duty  with  their  commands,  or  those  for  polico 
duty;  the  number  of  vacant  beds  in  their  ward,  giv- 
ing the  numbers  of  each;  and  also  a  weekly  report 
(every  Monday  ),  giving  the  name,  rank,  company, 
regiment,  division,  ward,  bed,  and  disease  of  each 
patient  under  their  charge.  They  will  write  and  tile 
with  the  division  surgeon,  for  the  action  of  the  exam- 
ining board,  and  not  commit  to  the  patients  them- 
selves, recommendations  for  furloughs,  transfers,  or 
discharges,  stating  in   each   the    regiment,   company, 


DUTY    OF    CLERKS. 


69 


bed,  ward,  and  disease  of  patient,  and  post-office  ad- 
dress, as  we'l  as  railroad  depot  nearest  to  their  desti- 
nation, and  notify  the  applicant  when  and  where  to 
appear.  In  no  ease  will  they  deliver  a  paper  to  an 
applicant  that  requires  action  of  a  superior  officer. 
They  will  write  upon  the  bed-ticket  the  diagnosis  of 
each  patient's  disease. 

One  assistant  surgeon  from  each  division  of  the 
hospital  /will  be  detailed  daily  as  officer  of  the  day. 
lie  will  visit  and  prescribe  for  any  patient  in  the 
division  who  may  require  his  services,  during  the 
day  or  night  while  he  is  on  duty,  writing  the  pre- 
scription for  such  in  the  prescription  and  diet  hook  of 
the  ward,  lie  will  inspect  each  ward  in  the  division 
every  six  hours,  and  will,  in  the  absence  of  the  divis- 
ion surgeon,  exercise  all  the  functions  pertaining  to 
that  officer.  When  relieved  from  duty  he  will  make 
a  report  in  full  to  the  division  surgeon,  of  everything 
that  may  have  transpired  in  the  division,  giving  the 
hours  of  his  different  visits  to  the  wards,  etc  When 
not  on  duly  in  the  wards  he  will  remain  in  the  oflicc 
of  the  division  surgeon,  so  as  to  be  readily  found  in 
ease  he  is  wanted. 

It  is  the  duty  of  the  clerk*  to  keep  the  books,  ami 
to  perform  all  such  writing  as  the  surgeons  may 
direct,  In  all  large  general  hospitals  a  clerk  is  as- 
signed  the  duty  of  baggage-master,  whose  duty  it  is 
t,>  receive  the  baggage  of  ail  patients,  properly  la- 
belled and  delivered  to  him  by  the  ward-master  01' 
head  nurse  of  each  ward,  to  whom  he  will  give  a 
oipt  lor  tin'  same,  delivering  the  baggage  to  the 
Bame  only  upon  the  retttrn  of  the  receipt.  The  bag- 
gage-room has  its  shelves  divided  into  as  many  com- 
partments as  there  are  beds  in  the  hospital,  into 
which   are  placed,  in  alphabetical   order,  the  properly 


70  DUTIES    OF    HOSPITAL   STEWARDS. 

of  the  patients,  the  baggage  always  being  labelled 
with  name  of  patient,  rank-,  company,  regiment,  «li vis- 
ion, ward,  bed,  and  post-office.  It  is  the  duty  of  tho 
baggage-master  to  see  to  the  safety  of  the  articles 
entrusted  to  Ids  care,  and.  for  their  better  protection, 
he  occupies  quarters  adjacent  to  the  baggage-room. 

The  hospital  &t*  wards,  receiving  commissions  from 
the  Secretary  of  War  after  an  approved  examination 
before  an  examining  board,  are  entitled  to  obedience 
from  all  enlisted  men  in  hospitals — both  patients,  ward- 
masters,  and  cmploj-ees — and  he,  in  turn,  owes  prompt 
obedience  to  the  commands  of  his  surgeon.  lie  should 
be  honest,  temperate,  intelligent;  writing  legibly  and 
correctly,  with  some  knowledge  of  book-keeping,  phar- 
macy, and  minor  surgery.  In  a  small  hospital  tho 
hospital  steward  has,  under  the  surgeon,  a  general  su- 
perintendence of  hospital;  regulates  its  police,  dis- 
cipline, ventilation,  lighting,  and  warming;  attends  to 
provision  returns;  carries  out  the  surgeon's  instruc- 
tions as  to  the  management  of  the  hospital  fund; 
makes  purchases  for  the  hospital;  takes  care  of  hos- 
pital stores;  sees  that  the  cooking  is  properly  per- 
formed; takes  charge  of  the  dispensary,  puts  up  pro- 
scriptions, as  well  as  renders  assistance  in  dressing 
of  wounds;  sees  that  tho  hospital  property  is  duly 
cared  for — and,  in  fact,  is  responsible  to  the  surgeon 
for  the  general  administration  of  the  institution. 

In  hospitals  of  one  hundred  beds  and  upwards, 
these  duties  become  so  onerous  that  two  hospital 
stewards  are  assigned  to  duty  in  the  same  institu- 
tion—one as  apothecary,  to  attend  to  the  dispensary 
and  the  dispensing  of  medicine;  the  other  as  mess 
Steward,  to  look  alter  the  administrative  duties  of  the 
hospital.  When  hospitals  are  as  largo  as  many  such 
establishments  now  in  full  operation  attached  to  our 


DUTY    OF   DRUGGIST.  71 

army,  comprising  from  one  thousand  to  four  thousand 
beds,  they  require  the  services  of  several  hospital 
stewards. 

To  each  division  of  such  a  general  hospital  there 
are  usually  two  or  more  commissioned  hospital  stew- 
ards— one,  and  sometimes  two,  acting  as  druggists, 
one  as  moss  steward,  to  look  after  hospital  property 
and  the  attendants,  and  one  as  clerk.  It  is  the  duty 
of  the  druggist  to  put  up  only  such  prescriptions  as  are 
written  out  by  a  medical  officer  of  the  division  to  which 
he  is  attached,  and  will  issue  nothing  unless  so  direct- 
ed, lie  will  use,  on  all  occasions,  the  scales  and  meas- 
ures in  the  compounding  of  medicines,  keeping  all 
apparatus  about  the  dispensary  scrupulously  clean, 
and  everything  in  order.  He  will  be  held  responsi- 
ble by  his  division  surgeon  for  the  proper  care  and 
dispensation  of  all  medical  supplies  committed  to  his 
charge.  Five  days  before  tho  end  of  each  month  he 
will  furnish  tho  division  surgeon  with  a  statement 
of  the  quantity  of  all  medical  supplies  on  hand,  and 
the  quantities  of  such  as  will  be  required  for  the  en- 
suing month.  None  but  such  as  are  authorized  will 
be  allowed  to  enter  the  dispensary. 

It  is  the  duty  of  the  clerk  to  keep  a  register  of 
the  daily  admission  of  patients  into  the  hospital,  to 
make  out  a  morning  and  monthly  report,  to  fill  out 
hospital  pay-rolls,  and  to  perform  any  other  duty  in 
writing  for  the  hospital  directed  by  the  surgeon. 

The.  mess  steward  takes  care  of  the  hospital  stores 
and  supplies,  receives  and  distributes  rations,  pre- 
pares provision  returns,  keeps  a  record  of  all  tho 
transact  ions  of  bis  department,  and  renders  a  written 

report  t<>  the  surgeon  at  the  end  of  every  month.  Ho 
takes  charge  of  the  valuable  effects  of  sick  and  de- 
ceased patients,  labelling  and  keeping  a  proper  regis- 


IZ  DUTIES    OF    WARD-MASTER. 

terof  the  same;  visits  daily,  and  reports  the  condition 
ol  the  sinks  of  his  division  to  the  Borgoanl  of  the 
police  guard  ;  ascertains  who  are  present  at  roll-call 
;ii  sunrise,  sunset,  and  tattoo,  and  reports  absentees, 
The  kitchen  and  cooks  are  placed  immediately  under 
his  supervision,  and  he  is  held  responsible  for  the 
cleanliness  of  the  kitchen,  as  well  as  for  the  proper 
preparation  of  the  food.  He  also  prepares  and  issues 
to  each  patient  a  meal-ticket,  receiving  the  samo 
at  the  door  when  the  patients  enter  the  mess-hall j 
at  the  same  time  supplies  them  each  with  a  knife, 
fork,  and  spoon,  which  each  must  return  to  the 
steward  as  he  leaves  the  hall  after  the  meal.  When 
a  steward  is  not  specially  assigned  to  the  duty  of 
looking  after  hospital  property  and  supervising  the 
servants,  the  mess  steward  must  consider  this  as  a 
portion  of  his  duties,  lie  is  also  expected  to  visit 
every  portion  ol'  the  establishment  three  times  eVery 
day,  the  last  visit  being  after  taps,  and  see  that  every- 
thing is  kept  in  perfect  order.  In  his  office,  in  a  con- 
spicuous place,  is  hung  up  a  table  containing  the 
names  of  all  the  attendants  of  the  institution,  with  a 
list  of  their  respective  duties. 

In  every  hospital,  and  in  each  division  of  an  exten- 
sive general  hospital,  there  is  a  general  ward-master, 
whoso  duty  it  is  to  commence  the  day  by  having  all 
the  wards  and  the  grounds  surrounding  the  buildings 
swept,  and  i he  dirt  collected  in  piles  ready  t'<>r  removal, 
and  also  to  see  thai  no  filth  accumulates  in  the  cham- 
bers or  buckets  about  the  wards,  lie  lakes  charge;  of 
the  effects  of  each  patient  upon  admission,  has  the  same 
properly  labelled  with  the  patient'fl  name,  rank,  com- 
pany, and  regiment,  together  with  the  ward  and  num- 
ber of  his  bod,  and  has  the  same  properly  registered 
in  a  hook  kept  for  that  purpose,  and  delivered  to  the 


DUTIES   OF   WARD-MASTER.  id 

baggage-master  to  be  stored  away  in  the  baggage- 
room.     When  a   patient    loaves    ilic  hospital,    all    of 

his  effects  are  restored  to  him  by  the  ward-master. 
Should  the  patient  be  discharged  from  the  arm}-,  it- 
is  the  duty  of  the  ward-master  to  retain  possession  of 
all  government  property  which  the  patient,  as  a  sol- 
dier, had  the  use  of,  and  when  such  accumulates,  to 
turn  over  the  saint4  to  those  officers  who  issue  them. 
All  money  and  jewelry  he  delivers  to  the  surgeon  for 
safe  keeping.  Ho  receives  from  tho  steward  the  fur- 
niture, bedding,  cooking  utensils,  etc.,  for  use,  keeps 
a  record  of  them  (Form  10,  Med.  Reg.),  and  a  st  a  le- 
nient of  how  distributed  to  the  wards  and  kitchens, 
and  once  a  week  renders  a  written  inventory  of  the 
same  to  tho  steward,  with  a  statement  of  any  loss  or 
damage,  returning  to  him  such  as  are  not  required  for 
use,  and  receiving  from  him  such  articles  as  are  neces- 
sary for  the  ensuing-  week. 

The  ward-master  distributes  to  each  chief  nurse 
in  a  ward  such  articles,  accompanied  by  an  inventory, 
as  the  comfort  of  tho  sick  may  require,  and  for  which 
those  receiving  are  held  strictly  responsible.  The 
ward-master  reports  daily  the  number  of  vacant  beds 
in  the  wards;  takes  charge  of  all  soldiers  returning 
to  their  regiments  at  the  clerk's  office,  and  conducts 
them  to  the  military  guard.  When  a  patient  dies,  he 
will  pin  on  his  breast,  previous  to  committing  I  lie  body 
to  the  "  dead-house,"  his  name,  rank,  regiment,  compa- 
ny, number  of  bed,  ward,  and  division  in  which  he  died, 
and  report  tho  same  to  the  division  surgeon.  They 
are  no!  allowed  to  receive  a  patient  in  their  wards 
unless  accompanied  hy  a  permit  from  the  division 
surgeon.  These  permits,  together  with  orders  for 
transferring  patients  from  beds  or  ward-  to  others, 
will  bo  carefully  preserved  as  vOucherf 
<; 


7  \  DUTY   OF    NURSES. 

In  general  hospitals  one  nurse  is  allowed  to  every 
ten  patients;  and  where  the  wards  contain  many  beds, 
a  head  nurse  presides  over  each  ward,  who  is  held 
responsible,  by  the  ward-master,  for  the  order,  disci- 
pline, and  cleanliness  ofthe  ward.  It  is  his  duty  to  Bee 
that  the  beds  are  kepi  constantly  arranged— all  cham- 
ber utensils  cleaned  immediately  after  being  used, 
ward  properly  kept,  meals  to  patients  confined  to  bed 
furnished  at  proper  hours  ;  that  the  medicines  arc  sent 
for  to  the  dispensary,  received  from  the  druggist,  and 
arranged  in  a  closet  prepared  expressly  for  this  pur- 
pose in  each  ward,  in  which  the  medicine  belonging  to 
each  patient  is  placed  at  a  number  corresponding  to 
the  bed  occupied  by  the  patient;  that  at  the  proper 
time  the  medicines  are  administered  to  the  patients 
as  directed  by  the  medical  officers;  that  the  patients 
obtain  such  diet  as  may  he  prescribed,  and  no  other: 
that  the  ward  is  properly  ventilated,  and  sufficiently 
warmed  in  winter,  and  that  the  police  regulations 
established  by  the  surgeon  in  charge  are  scrupulously 
complied  with,  lie  will  maintain  order  and  disci- 
pline among  attendants  and  patients,  and  will  report 
every  neglect  of  duty  and  disobedience  of  orders.  Ho 
will  allow  no  patient  to  keep  arms,  accoutrements) 
knapsacks,  or  packages  in  his  ward,  nor  to  intro- 
duce any  fruits  or  improper  diet. 

When  the  surgeon  visits  the  ward,  it  is  the  duty  of 
the  head  nurse  to  accompany  him  from  hed  to  bed, 
with  slate  or  memorandum-hook,  in  which  lie  will  note 
all  directions  of  the  surgeon  as  to  the  administration 
of  medicine,  diet,  etc.,  and  is  held  responsible  for  their 
proper  fulfilment,  lie  allows  no  patient  to  enter  his 
wai'd  without  a  bed-ticket  from  the  surgeon,  which  ho 
immediately  deposits  in  its  proper  receptacle  at  the 
head  of  the  bed  to  be  occupied.      He  will  promptly 


DUTY    OF    NURSES.  75 

report  the  departure  of  patients  from  his  ward  on 
furlough,  discharge,  desertion,  or  unauthorized  absen- 
tees, delivering  the  bed-ticket  of  the  same  himself 
to  the  clerk — never  allowing  patients  to  do  so.  Ho 
conducts  all  patients  returning  to  their  regiments 
to  the  clerk's  office,  after  having  procured  their 
baggage,  and  there  delivers  them  to  the  charge  of  (he 
ward-master.  He  receives  and  receipts  for  clothing 
to  he  washed,  to  the  patients  and  attendants  of 
their  respective  hods,  turns  them  over  to  the  matron 
in  charge  of  the  laundry,  and  takes  a  receipt  for  them. 
He  defines  the  duties  of  his  assistants.  As  these 
duties  are  responsible  and  important,  (he  chief  nurse 
of  a  ward  should  he  sober,  honest,  industrious,  intelli- 
gent, and  take  an  interest  in  his  duties. 

In  wards  of  over  twenty  heds,  the  head  nurse  ex- 
ercises chiefly  supervision  and  general  responsibility. 
The  heds  are  divided  equally  among  the  remaining 
nurses,  each  of  whom  is  held  responsible  for  all  that 
pertains  to  such  as  are  put  under  his  care,  lie  will 
insist  that  convalescents,  who  arc  able,  make  up  their 
beds  immediately  after  rising  in  the  morning,  and  will 
himself  arrange  the  heds  of  such  as  are  unable  to  do  it 
for  themselves.  The  assistants  arc  held  responsible 
for  the  cleanliness  of  their  patients — bathing,  wash- 
ing the  face  and  hands,  and  combing  the  hair  of  such 
as  are  unable  to  do  this  for  themselves.  In  every  in- 
stance, where  a  bed-pan  or  chandler  is  used,  the  nurse 
must  immediately  remove  it  from*  the  ward.  When 
the  personal  or  bedclothes  of  a  patient  are  soiled,  they 
should  also  he  changed  without  delay*  and,  when 
the  character  of  the  case  requires  it.  the  bedclothing 
should  lie  protected  b\  gutta-percha  (doth  or  oiled 
silk. 

It  is  the  duty  of  the  assistant   to  accompany  the 


prn     OS    M  RSES. 


surgeon  while  visiting  the  patients  under  his  charge, 
in nl  either  take  down  upon  a  memorandum-book  the 
directions  of  the  surgeon  as  regards  the  diet,  admin- 
istration of  medicines,  or  the  general  care  of  each 
patient,  or  have  free  access  to  the  memorandum-book 
of  the  chief  nurse.  For  such  patients  as  are  con- 
fined to  bed  he  will  obtain  the  prescribed  diet,  and 
will  see  that  all  who  are  able  will  eat  in  the  mess-hail. 
A 11  medicines  prescribed  the  nurse  will  administer  with 
his  own  hands;  and  to  facilitate  the  administration 
at  regular  periods,  it  is  customary  in  some  general 
hospitals  to  mark  the  day  by  adopting  ship  time — 

Bounding  the  bell  at  every  hall-hour.  For  instance, 
commencing  at  mid-day,  the  bell  is  struck  once  for 
half-past  twelve  o'clock,  twice  for  one  o'clock,  three 
times  for  half-past  one,  and  so  on  until  it  is  struck 
eight  tinier  for  lour  o'clock,  when  the  series  is  recom- 
menced. Besides  such  special  duties,  the  general  du- 
ties of  the  ward— as  sweeping,  scrubbing,  cleaning  of 
windows.,  management  of  tines,  cleansing  of  water- 
closets,  etc.,  bringing  of  meals  to  the  sick  who  are 
unable  to  visit  the  mess-hall,  etc., — are  distributed 
among  the  assistants,  the  head  nurse  making  the  as- 
signments. 

One  night-nurse  is  assigned  to  each  ward,  and  for 
each  division  a  head  nurse,  whose  duty  it  is  to  visit 
every  ward  every  hour  in  the  night,  to  inspect  the 
fires  and  lights,  and  see  that  the  nurses  attend  to 
their  respective  duties. 

The  arrangement  which  is  adopted  in  some  of  our 
large  general  hospitals  is  to  have  one  general  ward- 
master  for  a  division  of  the'  hospital ;  one  section  ward- 
master  to  a  section  of  four  wards,  or  ahout  one  hun- 
dred and  twenty  beds;  one  subward-master  or  head 
nurse   to  each  ward,   with   two   nurses  as  assistants  — 


DUTIES    OF    MATRON.  77 

these  being  usually  negroes — one  of  whom,  with  the 
sub  ward-master,  is  on  duty  every  day  in  each  ward 
of  thirty  beds.  At  night  one  nurse  is  left  in  each 
ward,  a  head  nurse  to  each  section,  and  a  ward- 
master  to  each  division,  so  that  the  nurses  are  on 
duty  for  twelve  hours  and  off  for  a  similar  period, 
while  the  other  officers  are  on  duly  all  day,  and  every 
fourth  night  alternating.  Night-nurses  are  never 
called  upon  to  assist  in  the  hospital  in  the  day. 

One  chief  matron,  with  an  assistant,  is  put  in  charge 
of  the  laundry  anil  linen-room.  Her  duty  consists  in 
receiving  from  the  nurses  the  soiled  clothes  from  their 
respective  wards,  both  of  the  patients  and  from  beds, 
marking  and  mending  these  before  they  are  sent  into 
the  laundry,  and  count  out  daily  to  the  laundresses  the 
number  of  pieces  to  be  washed,  requiring  the  same  num- 
ber to  be  returned  to  her  linen-room;  to  distribute  clean 
clothes,  both  for  beds  and  patients,  to  the  wards,  and 
report  to  the  surgeon  such  laundresses  as  may  fail  to 
comply  with  her  regulations,  or  may  extort  money 
from  soldiers  for  washing.  She  keeps  a  hook,  in  which 
is  entered  all  receipts  and  issues  of  both  soiled  and  clean 
clothes  from  patients,  as  Well  as  bed-linen,  giving  re- 
ceipts, enumerating  articles,  to  laundresses  and  nurses 
for  the  same. 

One  chief  matron,  with  an  assistant,  takes  charge  of 
the  pantry,  kitchen,  and  mess-room.  She  is  responsi- 
ble to  the  surgeon  for  the  proper  preparation  of  all 
diet,  and  for  the  cleanliness  of  her  department.  She 
provides  suitable  diet  and  delicacies  for  all  the  ill 
patients,  as  directed  by  medical  officers,  and  takes 
charge  of  all  stimuli  required  by  the  sick. 

An  important  officer  in  every  general  hospital  is  the 
sergeant  of  (he  guard,  who  is  responsible  lor  the  or- 
derly conduct  of  all  inmates  of  the  institution.       It  i- 


Tv  SERGEANT   OP   THE    Q1  Aim. 

his  duty  t<>  prevent  the  peace  and  comfort  of  the  sick 
from  being  disturbed  by  noises  in  the  precincts  of  the 
hospital.  He  sees  that  the  hospital  isproperly  guard- 
ed, day  and  night  j  that  oo  pationt,  attendant,  or  sub- 
officer  leave  the  institution  without  a  proper  written 
permission  from  the  Burgeon  in  charge;  and  that  the 
police  regulations  for  Btreets  and  sinks  are  daily  en- 
forced. He  takes  charge  of,  and  eon  duets  under  guard, 
discharged  soldiers  returning  to  their  regiments,  to  bar- 
racks, or  railroad,  as  he  may  ho  directed.  He  executes 
the  rules  and  regulations  pertaining  to  the  guard- 
house, and  makes  a  daily  report  to  the  surgeon  in 
charge  of  the  hospital.  The  guard  of  the  hospital 
mess  with  the  convalescents,  and  their  rations  are 
drawn  upon  the  provision  returns  of  the  hospital. 
When  a  detachment  from  the  post  guard  or  provost 
guard  can  not  he  obtained  for  a  hospital,  a  guard  can 
be  formed  from  such  soldiers  as  the  examining  hoard 
recommend  for  light  duty,  and  as  unfit  for  active 
field  servioe. 

Patients,  upon  arrival,  will  immediately  report  to 
the  central  register  office,  to  be  assigned  quarters. 
They  will  turn  over  all  arms,  accoutrements,  baggage, 
etc.,  etc.,  to  the  baggage-master,  receiving  a  cheek  for 
the  same.  They  will  not  be  allowed  to  smoke  in  the 
wards,  nor  spit  upon  the  floors  or  walls,  nor  commit 
nuisances  of  any  kind.  They  will  take  their  medi- 
cines as  directed,  and  abstain  from  the  use  of  fruits 
and  diet  forbidden  by  the  surgeon.  They  will  report 
themselves  to  the  clerk's  office  to  receive  bed-tickets, 
which  they  will  present  to  the  head  nurse  upon  enter- 
ing the  ward  tO  which  they  have  been  assigned. 
They  are  prohibited  from  loafing  about  the  clerk's 
office,  drug-store,  or  kitchen.  All  applications  for 
transfers,  furloughs,  and  discharges  must  be  made  to 


-     GENERAL    DISCIPLINE    OF    A    HOSPITAL.  79 

the  assistant  surgeon  of  their  wards,  which  will  be 
properly  forwarded — and,  if  granted,  be  returned  to 
them  at  their  wards.  They  will  obey  the  steward, 
ward-master,  nurses,  and  all  officers  of  the  hospital  ; 
and,  when  convalescent  and  fit  for  light  duty,  assist 
in  policing  the  hospital,  under  the  direction  of  the 
ward-master  or  commandant  of  the  guard. 

In  the  general  discipline  of  a  hospital,  the  surgeon 
in  charge  is  commandant  of  the  post  or  institution, 
and  exacts  implicit  obedience  from  every  inmate  of  the 
establishment,  and  he  is  expected  to  conduct  the  in- 
stitution in  accordance  with  the  rules  of  strict  mili- 
tary discipline.  As  the  responsibility  of  the  entire 
hospital  rests  solely  upon  the  surgeon  in  charge — the 
government  recognizes  no  other  chief — he  must,  in 
turn,  hold  his  assistants  to  a  strict  accountability;  and 
they,  in  turn,  their  subordinates — so  that  every  attache 
of  the  establishment  is  held  strictly  responsible  for 
everything  in  bis  keeping. 

In  all  well-regulated  military  hospitals  the  follow- 
ing regular  order  of  duties  is  observed :  Reveille  is 
called  at  five,  a.  m.,  in  summer,  and  six,  a.  m.,  in 
winter;  and,  fifteen  minutes  later,  the  morning  roll  is 
called  for  all  the  attendants,  who  immediately  after- 
ward commence  the  general  cleansing  of  the  hospi- 
tal. Such  convalescents  as  are  able,  alter  washing 
and  dressing  themselves — wash-rooms  being  provided 
in  all  hospitals — make  op  their  own  beds,  and  assist  in 
putting  their  portion  of  the  ward  in  order.  At  seven. 
a.  m.,  in  summer,  and  at  eight,  a.  m.,  in  winter,  is  the 
hour  for  breakfast,  when  all  convalescents,  and  such 
attendant-  as  are  not  required  in  the  wards,  assemble 
and  march  to  the  mess-room.  For  such  patients  as  are 
unable  to  leave  the  ward,  breakfast  ia  brought  by  the 
nurses,  and  those  who  can  not  feed  themselves  are  i'vd. 


GENEKAL    DISCIPLINE    OF    A    HOSPITAL. 

The  attendants  in  the  wards  take  their  meals  imme- 
diately alter  it  is  served  to  the  patients. 
•  The  chief  nurse  now  Bees  that  the  wards  are 
cleansed  and  put  in  thorough  order  for  the  sur- 
geon's call,  which  is  at  eighl  in  summer,  and  nine  in 
wintor.  At  these  hours,  when  the  call  is  sounded, 
each  patient  repairs  to  his  bed,  where  he  remains 
until  the  visit  is  completed,  while  each  medical  offi- 
cer commences  the  morning  visit  to  the  wards  ui 
his  charge.  The  medical  officer  examines  each 
patient  carefully,  and  the  prescription  and  diet  tor 
each  is  entered  in  a  book  kept  for  that  purpose. 
Aiur  the  visit,  these  hooks  an'  carried  to  the  dispen- 
sary, where  the  medicines  are  prepared,  and  duly 
labelled  with  ward,  bed,  name  of  patient,  date  of  pre- 
scription, dose,  ami  time  of  administration.  At  the 
same  time  the  steward  copies  off  the  diet  for  conva- 
lescents, and  also  the  prescribed  diet  for  the  sick, 
which  list  is  given  to  the  chief  matron  of  the  cooking 
department  to  he  prepared. 

Every  part  of  the  hospital  is  swept  thoroughly  every 
morning,  and  such  portions  in  which  dirt  accumulates 
are  res  wept  as  frequently  during  the  day  as  cleanli- 
ness requires.  The  kite  hen  Bhould  be  kept  as  clean 
as  tin;  wards,  ami  besides  the  early  morning  sweeping, 
Bhould  he  swept  jut-  after  every  meal.  The  grounds 
around  the  hospital,  with  the  walks,  should  also  ho 
swept  rvrvy  morning.  After  the  morning  use  of  the 
wash-room,  this  is  also  put  in  order,  ami  kept  so 
during  the  day.  The  privies,  after  being  thoroughly 
scrubbed  <  \rvy  morning,  are  put  in  charge  of  an  at- 
tendant or  guard,  who  inspects  them  after  their  use 
hy  every  patient,  in  order  to  fix  the  neglect  of  clean- 
liness upon  the  guilty  party.  These,  with  all  other 
portions    of   the    establishment,  are    whitewashed    as 


GEiNERAL    DISCIPLINE    OF    A    BOSPITAL.  Si 

often  as  neatness  requires.  A  tier  the  surgeon's  morn- 
ing visit  to  the  wards,  should  they  require  it,  the 
soiled  spots  upon  the  floors  are  washed  and  rapidly 
dried,  using  but  little  water  in  the  cleansing,  end  the 
entire  floor  is  well  scrubbed  with  dry  sand,  and 
swept.  This  dry-scrubbing  is  found  far  preferable  to 
the  flooding  of  the  wards  with  water,  which  causes  so 
much  annoyance  and  del  rinicut  to  the  patients.  During 
the  intervals  of  attendance  upon  the  sick,  the  nurses 
and  attendants  in  the  wards  will  find  ample  employ- 
ment in  keeping  tlie  floors,  walls,  and  windows  of  the 
wards  clean.  Bed-sacks  are  refilled  with  straw  at 
least  once  a  month,  at  which  time  the  ticking  should 
bo  washed  in  boiling  water. 

At  one,  r.  m.,  the  dinner-hour,  convalescents  .are 
again  marched  to  the  mess-room,  and  food  supplied 
to  those  detained  in  the  wards.  At  five,  p.  M.,  the 
surgeon's  afternoon  call,  the  patients  are  visited  in 
the  wards  as  in  the  morning.  Supper  is  served  at  six, 
v.  m.  At  eight  o'clock  tattoo  is  heat,  at  which  time 
the  night-watches  are  set  in  the  wards,  and  patients 
prepare  for  retiring.  At-  nine  o'clock  (taps)  all 
unnecessary  lights  are  extinguished,  and  all  patients 
must  be  in  bed.  The  steward  now  pays  his  third 
visit  to  the  wards,  to  see  that  everything  is  in  order 
for  the  night.  During  the  night  the  officer  of  the 
day  visits  frequently  tlie  wards.  Should  any  patients 
be  absent  from  their  beds,  the  nurse  reports  the  fact 
to  the  ward-master,  who  embodies  it  in  his  morning 
report.  On  one  daj  of  every  week,  usually  on  Sun- 
day, when  the  attending  surgeons  have  completed 
their  visits,  usually  between  eleven  and  twelve  o'clock, 
the  chief  surgeon  makes  a  general  inspect  ion.  The 
steward  goes  through  the  hospital  immediately  he- 
fore    the   surgeon's  visit,  to  see  that   everything   is   in 


82  OODK   OP   REGULATIOl 

order.  At  this  inspection  nothing,  either  in  tho  wards 
or  the  patit'iits.  should  escape  the  observation  of  the 
surgeon  Accompanied  by  liis  staff,  he  should  visit 
every  portion  of  his  establishment — wards,  kitchen, 
B tore-room,  baggage  room,  dispensary,  bath-room,  and 
privies.  During  tliis  inspection  of  the  wards,  each 
patient  romains  at  bis  bed. 

With  some  modifications,  the  following  will   com- 
a  code  of  regulations,  which  is  drawn  up  by  the 
surgeon,  to  be  printed,  and  posted  in  each  ward,  and 
other  conspicuous  places  in  the  hospital: 

CODE   01    KKoi  LA.TI0N8. 

1.  Xn  officer,  attendant,  or  patient  is  allowed  to 
leave  the  hospital  without  a  written  permission  from 
the  surgeon.  The  pass  will  be  shown  to  the  Bentinel 
on  |>'i-t.  on  issuing  from  the  institution,  and  given  to 
him  on  the  return  of  the  bearer. 

'1.   Profane  or  obscene  language,  and  disorderly 
duct  of  any  kind    is  strictly  forbidden  ;    and   no  Bpit- 
t i 1 1 lt  on  the  floor,  nor  defacing  in  any  way  the  walls, 
will  be  allowed.     Nor  will  Bmoking  be  allowed  in  the 
wards,  unless  by  special  permission  of  the  surgeon. 

8.  No  patient  shall  be  admitted  into  a  division 
without  a  ticket  of  admission  from  the  surgeon  in 
ohargo;  nor  into  a  ward  without  a  ticket  from  the 
division  surgeon;  nor  returned  to  duty  until  reported 
to  the  division  surgeon.  Nor  shall  transfers  of  pa- 
tients from  one  bed  or  ward  to  another  be  allowed, 
unless  ordered  by  the  division  surgeon. 

4.  The  beds  are  to  !>»•  made  up  every  morning  by 
attendants,  or   oftener,  if  necessary.     Convalescents 

who  are  able  must   make  u j >  their  own  beds. 

5.  No  patient  will  oconpy  his  bed  without  undress- 
ing- 


CODE    OF   REGULATIONS.  83 

6.  Every  patient,  who  is  able,  will  wash  his  face  and 
hands  at  Least  every  morning,  and  keep  the  rest  of 
his  body  clean.  Those  unable,  will  be  attended  to  by 
the  nurses.  Every  patient,  whose  condition  does  not 
forbid  it,  will  take  a  hath  upon  admission. 

7.  During  the  morning  visit  of  the  surgeon,  every 
patient  and  nurse  must  he  in  the  ward,  and  patients 
■who  are  able  will  stand  at  the  side  of  their  beds  until 
examined  b\  the  surgeon. 

8.  All  patents  must  be  in  bed  at  nine  o'clock, 
when  all  lights  are  extinguished,  unless  otherwise 
directed,  except  in  the  office,  and  one  in  each  ward, 
which  will  be  lowered.  All  talking  in  the  ward  is 
prohibited  after  this  hour. 

9.  Xo  patient  or  nurse  will  be  allowed  to  enter  the 
office,  dispensary,  or  kitchen,  unless  on  business. 

10.  No  provisions, no  spirituous  liquors  of  any  kind, 
shall  be  brought  within  the  hospital  without  the 
permission  of  the  medical  officer  of  the  day,  nor  will 
friends  or  relatives  of  the  patients  be  allowed  to 
distribute  such  articles  without  permission  of  tho 
surgeon  of  the  ward. 

11.  Patients  will  give  prompt  obedience  to  tho 
steward,  ward-master,  and  nurses,  in  all  lawful 
commands.  Any  infractions  of  discipline,  disobedi- 
ence of  orders,  drunkenness,  or  disorderly  conduct,  will 
be  promptly  punished. 

12.  Patients  and  attendants  arc  requested  to  report 
promptly  to  the  division  surgeon  any  neglect  of  duty 
on  the  part  of  any  attendant  or  officer,  deficiency 
of  diet,  loss  of  clothing  Bent  to  the  laundry,  etc. 
In  case  the  division  surgeon  does  not  give  redress,  the 
matter  will  (when  their  is  ju>t  -round  of  appeal)  be 
laid  before  the  surgeon  in  charge  for  final  action. 

13.  All  official  communications  must  he  sent  through 
the  proper  channel. 


84      HOSPITAL  REGULATIONS  As  REGARDS  PATIENTS. 

I'])"1  the  arrival  of  a  patient  a1  a  general  hospital, 
he  is  al  once  carried  to  the  office,  where  his  order  for 
ri<lii*I  —  i- »i*  is  taken  and  ti!."l  away,  as  also  his  descrip- 
tive list,  so  thai  the  Burgeon  in  charge  may  en 
upon  it  all  payraonts,  stoppages,  and  issues  of  clothing 
which  may  !».•  made  to  him  while  in  the  hospital. 
Should  the  patienl  bo  ordered  to  hospital  without  this 
descriptive  list,  it  will  be  the  duty  <>t  tho  clerk  to 
obtain  one  from  the  commander  of  the  company 
to  which  the  patienl  belongs.  His  name,  rank,  compa- 
ny, regiment,  etc.,  etc.,  having  been  carefully  regis- 

.  his  effects  are  turned  over  to  a  ward-master,  who 

has  them  duly  entered  upon  tho  1 k  kepi    for  this 

purpose  by  tho  baggago-master,  and  put  away  in  the 

ige-room.  Any  money  and  other  valuables  which 
he  may  haw  are  givon  to  the  steward  or  Burgeon  for 
safe-keeping  and  a  receipt  given  to  the  patient  for  the 
same.  Such  items  arc  also  duly  entered  in  a  book  kept 
for  that  purpose,  lie  should  then  bo  carried  to  the 
bath-room,  unless  bin  condition  forbids  it.  and  finally 
is  received  into  a  ward  where  a  hod  has  boon  assigned 
him. 

The  following  form  of  bed-ticket  is  placed  in  a  con- 
venient  frame,  at  each  bod,  and  forms  a  succinct 
synopsis  of  the  history  of  each  patient.  When  filed; 
these  comprise  a  duplicate  register: 


Division 

Name  — 


GENERAL    llosl'i  I  \l,. 

_,  Ward -,  Bed 

\     . 


Residence  or  post  -office 

Regiment .  <  Jompany 

Previous  ocoupation . 

Admitted . 


W  here  from 


-.  By  whose  order 


I10SPITAL  REGULATIONS  AS  REGARDS  PATIENTS.      85 


Disease ,  Dale  of  commencement 

Scat ,  Character  of  wound . 

When ,  Where  received . 


Operation . 

Dale  of ,  Result 

Supervening  disease 


Final  disposition ,  Pate 

Remarks. 


-,  Ward  Surgeon. 

On    the    back  of  this  bed-ticket  may  be  placed   a 
statement  of  the  effects  of  the  patient,  as  follows  : 


AKTICI.ES. 

NOS.        ! 

ARTICLES. 

NOS. 

Uniform-coat 

Socks 

In  leaving  the  hospital,  the  patient  is  turned  over  by 
the  head  nurse  of  the  ward  which  he  occupied,  with 
his  bod-tickot,  i"  the  ward-master,  who  conducts  him 
to  the  clerk's  office,  where  he  obtains  his  descriptive 
list,  endorsed  by  the  aurgeon,  showing  the  state  of  Ids 
account,  ami  also  his  discharge  papers,  and  such  valu- 
ables as  he  left  in  charge  of  the  9urgeon.  It'  the  pa- 
tient is  discharged  from  the  army,  it  is  the  duty  «>f 
the  hospital  Burgeon  to  make  out  his  final  statement 
of  pay  and    clothing.        He    i>    then  conducted    by  the 

ward-master  to  tho  baggage-room,  from  which  his  ef. 
fects  are  obtained,  when  he  is  turned  over  to  the  mili- 
tary guard,  to  be  conducted  to  the  rendezvous  appoint- 
ed t"i-  -'nli  as  are  ready  to  return  to  the  army.  This 
plan  of  keeping  discharged  patients  under  guard  until 


86  l  OPACITY   01    HOSPITALS. 

they  are  returned  to  their  regimental  commanders 
has  been  found  necessary,  on  account  of  the  general 
disposition  of  soldiers  discharged  from  hospital  to  loi- 
ter for  days,  and  sometimes  for  weeh  rejoining 
their  commands. 

In"  every  hospital,  over-crowding  is  always  to  |bo 
guarded  againBl  ;  and,  as  a  certain  number  of  cubic 
feel  are  allowed  each  patient,  hospital  surgeons  are  in- 
structed to  have  a  statement  of  the  cubic  measure  and 
capacity  of  each  ward  placed  conspicuously  in  oaoit, 
so  that  the  inspector,  at  a  glance,  can  see  that  this 
important  regulation  against  crowding  is  observed. 
The  number  of  cubic  feet  allowed  each  bed  of  a  ward 
is  eight  hundred  ;  hut  as  height  docs  not  compensate 
for  area — as  all  the  dangerous  gases  Btagnate  in  the 
lower  strata,  near  the  floor  of  the  room — it  would  he 
bettor  to  allow  each  patient  so  many  square  feet,  say 
eighty  square  feet,  tor  each  bed.     For  those  who  are 

sick  with  typhus-fever,  or  the  severely  wounded,  twice 
this  area,  or  at  least  one  hundred  square  feet,  will  not 
he  too  much  Bpaco,  if  it  he  desirable  to  prevent  pyae- 
mia, hospital  gangrene,  orysipelas,  and  othor  fatal 
complications, from  showing  themselves.  Rooms  with 
Less  than  ten  feet  ceiling  are  not  lit  accommodation 
for  the  sick. 

With  a  constant  tendency  to  a  poisoning  of  I  he  ai- 
mOSphere "from    imperfect    ventilation,  all    precautions 

of  cleanliness  can  not  he  too  rigidly  enforced.  In  the 
cleansing  of  hospitals,  too  frequent  scouring  is  preju- 
dicial to  the  sick,  and  is  found  to  induce  low  forms  of 
disease.  In  French  hospitals,  the  wooden  floors  are 
waxed  and  rubbed  daily,  which  avoids  the  excess  of 
moisture  in  the  atmosphere  of  a  ward.  In  our  mili- 
tary hospitals  (he  floors  are  sanded  and  dry-scruhbed 
daily,  only  the  very  dirty  Bpots  being  washed.  Eveiy 
ten  davS  or  a  fortnight  the  entire  floors  arc  washed  over. 


CLEANLINESS    IN    HOSPITALS.  87 

Spittoons  should  be  furnished  to  every  bed,  and  the 
sick  should  be  prohibited  from  spitting- upon  the  floors. 
These  spittoons  should  be  cleansed  daily,  and  newly 
sanded;  and,  when  much  used,  the  sand  should  be 
changed  twice  daily,  or  they  may  become  offensive  and 
injurious.  All  urinals,  bed-pans,  and  chamber-pots 
should  be  emptied  as  soon  as  used,  and  never  be  ill- 
lowed  to  remain  soiled  in  the  ward.  The  bunks  in  the 
hospital,  after  being  in  use  for  three  or  four  weeks, 
should  be  taken  out  of  the  wards,  well  scoured,  and 
exposed  to  the  weather,  before  they  are  returned.  As 
soon  as  a  bed  is  vacated,  if  it  has  been  in  use  moro 
than  ten  or  fifteen  days,  the  straw  should  be  burnt 
and  the  sack  washed  and  refilled.  Blankets  should  also 
be  frequently  changed  and  washed.  Personal  cleanli- 
ness is  essential  in  a  general  hospital.  If  conveniences 
are  at  hand,  the  patient,  upon  admission,  should  bo 
bathed  and  placed  in  clean  clothes,  and  in  a  clean  bed. 
The  beds  should  always  be  kept  in  order,  whether  oc- 
cupied or  not,  and  should  a  patient  leave  it  only  for  a 
few  minutes,  it  should  be  put  in  order  by  the  attending 
nurse  while  he  is  out  of  it. 

Such  a  general  hospital  should,  among  other  things, 
be  liberally  furnished  with  hospital  clothing,  which,  in 
Confederate  hospitals,  consist  only  of  shirts  and  draw- 
ers. In  European  general  military  hospitals  the  pa- 
tient leaves  everything  behind  him  when  he  enters  its 
wards.  He  receives  a  hath,  and  is  dress, m1  up  in  tho 
hospital  clothes;  his  own  arc  washed  and  stored  away, 
properly  labelled  by  the  ward-master.  SliMuld.be  bo 
suffering  under  any  contagious  disease,  as  the  itch,  ty- 
phus lever,  etc.,  his  clothing,  after  being  well  washed  in 
boiling  water,  are  fumigated  lor  twenty-four  hours  in 
a  closed  chamber  or  tent  with  chlorine  gas.  With  itch 
patients,  sulphur  fumigations  are  substituted  for  chlo- 

rl  n  Q  * 


CLEANLINESS    IN    B08PITA 

Tho  ward-master  should  nevorallow  the  wards  of  a 
hospital  to  be  encumbered  with  the  packages  or  ac- 
coutrements of  the  inmates,  but  all  Boch  should  be 
stored  away  in  a  Btore-room,  where  a  Beriee  of  pi 
holes,  two  feel  square,  are  arranged,  and  numbered  as 
arc  the  beds,  so  that  each  inmate  of  the  hospital  has  a 
square  allotted  to  bim  wherein  to  deposit  his  private 
stores.  Where  the  hospital  is  well  organized,  every 
article  which  the  patient  brings  in  is  deposited  in  the 
Btore-room. 

Whenever  an  infectious  or  contagious  epidemic 
threatens  to  invade  a  hospital,  the  vigilance  of  the 
sanitary  police  of  the  institution  should  be  redoubled, 

in  order  to  remove  or  counteract  those  causes  which 
might  assist  in  producing  or  disseminating  such  dis- 
ease. A  thorough  examination  of  the  building  should 
be  made;  all   offal,*  of  whatever  character,  should   be 

removed  as  BOOn  as  discovered.  This  relates  especially 
to  the  using  of  chamber  utensils  in  the  wards,  which, 
under  no  circumstances,  should  bo  allowed  to  remain 
soiled.  Cleanliness  in  every  depart  men!  musl  he  en- 
joined. The  diet  of  the  patients  should  he  improved 
in  quality,  and  more  liberally  distributed;  and  wine, 
or  some  stimulating  drink,  should  be  given  to  conva- 
lescents, who  should  be  examined  daily,  so  that  any 
irregularity  in  the  functions  ol  their  digestive  organs 
may  he  corrected.  Free  ventilation  of  the  building, 
the  frequent  changing  of  bedding,  avoidance  of  all 
crowding  in  the  ward,  ami  an  increase  in  the  number  of 
cubic  feet  to  cadi  patient,  the  separation  of  convales- 
cent-, who  should  he  sent  away  from  the  infected 
building,  the  early  burial  of  the  dead,  both  for  its 
moral  as  well  as  hygienic  benefit,  are  some  of  the  many 
precautions  which  surgeons  in  charge  of  hospitals  will 
adopt 


VENTILATION    OF    HOSPITALS.  89 

When  any  low  form  of  disease  makes  its  appear- 
ance in  a  ward,  this  portion  of  the  building  should  bo 
temporarily  closed  for  the  reception  of  patients,  and 
should  undergo  a  thorough  cleansing  and  whitewash- 
ing. Heating  the  air  contained  within  the  closed 
room  by  means  of  stoves,  so  as  to  attain  a  high  tempe- 
rature, or  fumigations  with  chlorine  may,  at  times,  be 
required  to  destroy  the  fomitcs  causing  the  disease, 
and  render  the  ward  again  habitable.  This  closing 
and  general  cleansing  should  also  be  adopted  when- 
ever a  ward  has  been  occupied  for  a  length  of  time  by 
those  seriously  injured,  suffering  with  extensively  sup- 
purating wounds.  Should  any  one  enter  at  midnight 
a  ward  thus  inhabited,  the  insufferable  smell  and  the 
sensation  of  oppression  from  inhaling  the  atmosphere 
would  at  once  explain  the  danger  from  low  forms  of 
infectious  diseases,  and  the  necessity  for  not  only  con- 
slant  cleanliness  and  continued  ventilation,  but  also 
for  purifying  the  same  at  intervals. 

Stronger,  in  his  Maxims  of  Military  Surgery,  based 
upon  experience  and  observation  during  the  Schleswig- 
Holstein  war,  states  that  such  rooms  should  be  thrown 
out  of  use  for  two  weeks  after  every  two  months  oc- 
cupation. This  he  lays  down  as  an  important  hospital 
regulation.  Chemical  disinfectants  were  not  found 
useful  by  him  as  long  as  the  rooms  were  occupied;  the 
rooms  must  be  vacated.  For  occupied  rooms,  draughts 
of  fresh  air  are  the  only  good  disinfectants ;  and  to  obi  ain 
this  end,  without  detriment  to  the  sick,  the  windows 
should  open  near  the  ceiling,  and  the  sashes  should  ho 
so  arranged  that  the  upper  one  can  be  lowered,  which 
admits  fresh  air  without  pouring  a  cold  current  direct- 
ly upon  the  sick.  The  Blight  exposure  t'>  catarrhal 
affections  is  not  to  be  considered,  when  compared  to 
the  danger  of  introducing  infoctious  diseases,  by  per- 
il 


dim.nh  -  CAS 

knitting  a  foal  and  unrenewed  atmosphere  to  be  inhaled 
bj*  the  wounded.  It  is  owing  to  the  advantages  for 
ventilation  that  tents  arc  bo  much  better  than  wards 
for  typhus  and  severely  wounded  pationtn,  the  more 
especially  when  wounds  show  a  Bloughing  tendency. 
Pure  air,  continually  renewed,  is  essential  for  the  cure 
of  typhus  and  hospital  gangrene.  Abundance  of  fresh 
air  covers  a  multitude  of  in* venienc< 

In  the  arrangement  of  a  Confederate  military  hospi- 
tal of  recent  construction,  this  general  imperfection 
of  ventilation  is,  to  a  great  extent,  obviated.  The  one- 
story  frame  building,  with  boards  not  fitting  very 
closely  together,  and  a  permanent  ventilator  in  the 
roof,  creates  continued  interchanges  of  air,  which  en. 
ables  the  patients  to  live  in  a  constantly  renewed  atmos- 
phere. This  will  account,  t<>  a  great  extent,  lor  the 
comparatively  small  mortuary  percentage  in  the  mili- 
tary hospital  practice  of  the  Confederate  States — being 
an  average  of  about  four  per  cent.* 

In  the  Crimean  service,  the  French  attached  great 
importance  to  the  fumigation  of  their  wards.  The 
surgeons  of  their  immense  military  hospitals  thought 
that  they  derived  decided  benefit  from  adopting  the 
Turkish  custom  of  fumigating  with  dried  Bage,  which 
was  burnt  in  the  wards  three  times  a  day,  in  addition 
to  the  use  of  chlorine  fumigations  morning  and  even- 
ing. 

A  saucer  of  chloride  of  lime  was  also  placed  under 
the  bed  of  each  typhus  patient.  It  is  a  question 
whether  these  fumigations  act  from  the  medicinal 
virtues  which  tiny   possess,  or  upon  hygienic  princi- 

*A  consolidated  report  of  tho  hospitals  in  the  Department  of  Virginia, 
j  r> >ni  September,  1862,  to  December,  1863,  inclusive,  prepared  by  Sur- 
geon W.  A.  drriugton,  Medical  Director,  gives  total  admitted,  293,165  j 
deaths,   10,2-18. 


DISINFECTANTS.  91 

pies.  The  European  nations  have  such  a  dread  of 
draughts,  that  a  door  or  window  is  never  left  open, 
which  induces  the  belief  that  they  were  intended  to 
give  light  and  not  air. 

This  difficulty  of  ventilation  through  the  windows, 
which  are  the  proper  media  for  it.  is  the  common 
subject  of  complaint  among  the  medical  si  all' of  hospi- 
tals. Stromyer  had  to  enter  into  a  regular  compact 
with  his  (xerraan  patients.  He  would  only  allow 
bhera  to  smoke,  provided  they  would  keep  the  win- 
dows open,  using  this  subterfuge  to  ventilate  the 
wards.  A  celebrated  English  medioal  lecturer  placed 
the  value  of  fumigations  in  their  true  light,  when  he 
said:  "Fumigations  are  of  essential  importance}  they 
make  such  (in  abominable  smell  that  they  compel  you  to 
Open  the  windows."  When  these  means  are  used,  with- 
out affording  the  impure  air  means  of  escape,  they 
only  act  as  masks  —  disguising,  by  their  strong  odors, 
the  offensive  and  injurious  exhalations  from  the  sick. 
They  quiet  the  anxieties  of  the  nurse,  without  in  any 
way  benefiting  the  patient. 

It  must  never  he  forgotten  that  many  symptoms 
which  are  said  to  belong  to  a  disease,  depend  upon 
the  circumstances  under  which  it  is  contracted  or 
treated,  and  many  of  these  can  with  truth  lie -accred- 
ited to.  had  ventilation;  hence  the  different  phases 
which  diseases  assume  under  treatment  in  hospitals 
when  contrasted  with  cases  in  private  practice.  If 
such  causes  will  produce  disease  (a  tact  with  which 
©very  one  is  familiar),  how  much  more  likeiy  are  they 
to  modify  those  already  existing'.'  Every  physician 
of  experience   ami  observation   has   seen   serious  cases 

of  fever,  which  threatened  a  fatal  issue,  commence  to 
improve  from  the  moment  that  the  patient  was 
changed    from    the   room   in  which    he   had   long  been 


92  RULES   "F    HYGIENE. 

lying,  with  its  closed  windows  and  musty  smell,  to  a 
light,  cheerful,  well-ventilatod  chamber.  This  is  al- 
ways attributed  to  change  of  scene,  while  the  true 
cause,  change  of  air,  is  overlooked. 

Typhus  patients,  and  cases  of  hospital  gangrene 
particularly,  should  always  be  treated  in  tents,  and 
ample  room  he  given  to  each.  Over-crowding  is 
certain  to  produce  such  a  condition  of  the  atmosphere 
as  to  heighten  the  mortality.  It  also  becomes  im- 
perative upon  those  taking  care  of  such  infectious 
patients  to  breathe  the  air  as  little  as  they  can;  live 
out  of  the  room  ok  tent  as  much  as  possible,  compati- 
ble with  the  proper  attendance  upon  the  sick. 

Surgeons  placed  under  such  circumstances,  in  a 
badly-ventilated  hospital,  must  take  additional  care 
of  themselves.  Personal  cleanliness  becomes  a  ne- 
cessity; the  liberal  use  of  the  hath,  and  the  frequent 
changing  of  their  clothing,  will  be  found  a  wise  sani- 
taiy  precaution.  Their  diet  should  consist  of  simplo 
and  easily  digested  food,  with  stimuli  in  moderation. 
They  should  avoid  all  excesses,  both  in  eating  and 
drinking — as  those  addicted  to  intoxication  and  gor- 
mandizing are  placed  in  the  same  category  with  the 
weak  and  poor,  from  which  classes  the  mortuary 
tables  m;  epidemics  are  chiefly  made.  In  taking  ex- 
ercise in  the  open  air,  fatigue  must  be  avoided.  His 
mind  must  be  free  from  all  anxiety  or  personal  fear  of 
the  disease,  lie  should  take  a  full  proportion  of 
sleep,  and  in  the  general  care  of  his  person  should 
watch  eveiy  indisposition,  and  correct  derangements 
of  the  digestive  system  before  they  lead  to  more 
serious  conditions. 

The  medical  attendants  in  typhus  hospitals,  or  in 
such  as  are  infested  with  pyajmia,  gangrene,  etc.,  should 
frequently  change  places  with  those  in  charge  of  more 


FEMALE    NURSES    IN    HOSPITALS.  93 

healthy  institutions;  otherwise,  the  permanent  medi- 
cal attendant,  inhaling  daily-  this  poisoned  atmosphere, 
will  he  sacrificed  to  an  absence  of  a  regular  interchange 
of  stations  and  duties. 

In  the  best  regulated  hospitals  each  typhus  case 
has  two  beds.  Every  twelve  hours  he  is  changed, 
and  the  bedding  upon  which  he  has  been  lying  fumi- 
gated and  well  aired.  The  bed  and  body  linen  of 
sueh  patients  should  also  be  changed  dailyT.  As  ty- 
phus is  known  by  its  infecting  nature  and  its  easy 
transmission,  the  hospital  wards  can  not  be  protected 
by  too  many  hygienic  regulations.  When  a  hospital 
has  become  infected  with  typhus,  pyemia,  or  hospital 
gangrene,  it  is  best  to  close  it  and  turn  out  all  pa- 
tients. It  would  be  much  safer  for  the  sick  and 
wounded  to  stay  in  the  streets  or  lie  in  the  field,  than 
be  sent  to  such  an  infected  establishment.  His  per- 
mit for  admission  is  his  death  warrant,  while  com- 
bating the  elements  would  give  him  at  least  a  chance 
for  successful  treatment.  Any  temporary,  well-ven- 
tilated structure — a  hut  rudely  made  of  rough  boards 
— or  a  tent — would  be  infinitely  preferable  to  gorgeous 
palaces  with  gilded  chambers,  in  which  Death  sits  in 
Mate  to  receive  his  victims. 

In  general  hospitals  the  blessings  of  a  woman's 
care,  her  ever-watchful  eye  and  soothing  words,  her 
gentleness  and  patience,  have  added  largely  to  tho 
Comforts  of  the  sick.  Florence  Nightingale,  when  she 
made  her  disinterested  otfer  to  nurse  the  sick  in  the 
Crimea,  could  have  little  foreseen  the  new  era  dawn- 
ing for  suffering  humanity,  and  the  benefits  which 
she  was  bestowing  upon  future  generations. 

It  is  woman's  peculiar  prerogative,  as  it  is  her  earth- 
ly mission,  to  give  comfort  to  those  in  distress;  and 
when  the  English  adopted  the  custom  long  prevalent 


Ml  1  All     NURSES    IN     HOSPITALS. 

in  Franco,  to  allow  female  nurses  to  minister  t<>  the 
wants  of  those  Buffering  in  military  hospitals,  the 
wounded  felt  that  half  their  Bolicitude  was  removed. 
Now  a  Sister's  care  will  bathe  the  Bufferer's  aching 
head,  or  offer  biro  the  cooling  draught  to  allay  bis 
parched  thirst;  will  sympathise  with  liis  pains,  and 
give  sweet  consolation  to  bis -dejected  -s]>iri t  ;  and,  by 
removing  that  overpowering  weight  of  loneliness,  by 
which  the  sick  in  hospital  far  from  home  and  friends 
are  oppressed,  will  often  pave  the  road  to  speedy  con* 
valescence.  A  cheerful  look,  a  kind  word,  a  pleasant, 
smile  from  one  of  these  self-denying  Sisters,  has 
many  a  thrill  of  pleasure  through  a  stricken  souL  The 
Burgeon  sees,  at  his  next  visit,  the  fruit  of  this  pleas- 
antly-administered draught,  which,  perhaps,  be  blindly 
attributes  to  his  own  nauseous  drugs. 

The  experience  of  Confederate  hospitals,  in  recog- 
nising the  vast  amount  of  good  which  female  nurses 
accomplish,  and  the  incalculable  service  which  they 
are  capable  of  performing,  when  judiciously  selected 
and   properly   organized,    is  a   sufficient    reason  why 

they  should  he  attached  1"  every  hospital,  and  .spe- 
cially in  times  Of  war,  when    their  many  and   peculiar 

services  can  uo1  be  dispensed  with.     To  the  BurgeOn,  a 

gOod,  kind,  reliable  nurse  constitutes  more  than  half 
the  treatment  of  the  sick.  It  is  with  the  most  serious 
that  their  advantages  in  nursing  are  best  dis- 
played. McLeod,  who  studied  carefully  woman's  ser- 
vices in  the  Crimean  hospitals,  says:  "A  woman's 
services   in   a  hospital    are  invaluable,    if  they  were  of 

bo  further  use  than  to  attend  to  the  cooking  and  the 
linen  departments;  to  supply  'extras'  in  the  way  of 
little  comforts  to  the  worst  cases;    to   see  that    the 

medicines   and    wine   ordered  are   administered  at  tho 

appointed  periods,  and  to  prepare  and  provide  suita- 
ble drinks. 


FEMALE    NURSES    IN    HOSPITALS.  95 

"As  to  the  employment  of  'ladies,'  I  think  they  are 
altogether  out  of  place  in  military  hospitals,  exeept 
as  superintendents.  As  heads  of  departments,  :is  or- 
ganizers, as  overlookers,  'officers'  of  the  female 
corps,  if  you  will,  they  can  not  he.  dispensed  with; 
but  for  inferior  posts,  strong,  active  respectable  paid 
nurses,  who  have  undergone  a  preliminary  training  in 
civil  hospitals,  should  alone  he  employed.  In  camp 
hospitals,  which,  with  an  army  in  the  field,  are  merely 
the  temporary  resting-places  of  the  sick,  men  should 
alone  he  employed  as  nurses;  but  in  the  more  fixed 
hospitals  in  the  rear,  the  lady  superintendents  and 
ttnder-nurses,  should,  in  my  opinion,  always  he  added 
to  the  regular  staff.  Their  attention  should  be  limited 
to  the  had  cases,  and  they  should  have  the  entire  con- 
trol ol'  the  linen,  medical  comforts,  and  cooking. 

"All  cleaning  should  be  done  by  men.  There 
should  be  a  lady  superintendent  over  each  division 
of  the  hospital,  responsihle  to  the  surgeon  as  well  as 
to  her  own  lady  chief.  Then  there  should  be  a  store 
of  'extras'  under  her  charge,  distributable  on  requisi- 
tion from  the  medical  attendant,  and  which  depot 
should  he  filled  up  to  a  certain  quantity  weekly,  the 
Sister  being  held  accountable  for  the  contents.  Wine 
and  all  extras  should  pass  through  her  hands.  She 
should  be  responsihle  for  the  due  performance,  by  her 
female  subordinates,  of  their  duties,  and  have  a  right 
to  interfere  with  the  ward-master  if  the  cleaning, 
etc.  is  not  properly  attended  to  by  his  male  corps." 

The  material  of  which  the  Confederate  army  is 
composed  differs  so  totally  from  that  of  armies  ordi- 
narily—  the  ranks  being  made  up  of  the  besl  people 
of  the  land — that  ladies,  forming  the  society  of  the 
country,  have  taken  a  very  conspicuous  pari  not  only 
in   the  formation,  bat  in  the  preservation,  of  our  ar- 


HOSPITAL    DIKT. 

mics.  They  have  given  ap  their  sons,  husbands,  and 
fathers  willingly  to  their  country's  call  ;  have  fed  and 
clothed  them  while  in  the  field  ;  ami  when  stricken 
down  by  disease,  or  the  enemy's  missile,  they  have 
taken  their  }»la<i-s  by  the  oouch  ol  pain,  and,  by  their 
gentle  and  assiduous  attentions,  have  mitigated  large- 
ly the  horrors  of  war.  They  have  established  hospi- 
tals, ami.  by  private  means  ami  their  individual  efforts, 
have  successfully  conducted  large  establishments — liv- 
ing memorials  of  their  patriotism  and  devotion. 
Without  the  instrumentality  of  the  nohlo  women  of 
the  Confederate  Stales,  in  toning  political  opinions, 
in  infusing  the  fire  of  patriotism,  in  dispelling  doubts, 
fears,  and  i^loom,  in  exhibiting  a  courage  and  bold- 
nes.s  in  the  presence  of  danger,  an  unshaken  con- 
fidence in  ultimate  BUCCOSS,  a  settled  faith,  a  bound- 
less liberality,  ami  a  devotion  to  the  soldier,  our 
struggle  for  independence  would  have  been  a  much 
more  serious  undertaking,  and  success  much  more 
doubtful. 

The  dieting  of  patients  in  <i  hospital  is  always  a 
matter  of  considerable  moment,  and  one  which  re- 
quires much  attention,  'flic  surgeon  has  discretion- 
ary powers  to  order  any  extras  which  the  patients 
may  need,  and  which  the  issue  of  rations  does  not 
include.  To  be  enabled  to  supply  these  extra  articles 
at  a  time  when  they  are  wanted,  the  surgeon  in 
charge  of  a  hospital  is  furnished  with  funds,  tor  the 
judicious  outlay  of  which  he  becomes  personally  re- 
f-pousihle. 

This  hospital  fund  for  supporting  the  commissariat 
of  a  hospital,  is  collected  by  commuting  the  number 
of  rations  which  the  patients  are  entitled  to  draw,  at 
a  certain  rate,  changed  from  time  to  time  by  the 
government.     The  hospital   is  allowed   to  purchase  at 


nospiTAL  i>ikt.  97 

cost  such  articles  as  the  commissary  department  can 
furnish,  which  amount  is  charged  against  the  daily 
allowance  and  the  hospital  credited  with  the  differ- 
ence, which  may  he  either  left  in  the  hands  of  the 
commissary,  he  paying  all  bills  contracted  for  the 
comfort  of  the  sick,  when  approved  by  the  surgeon 
in  charge,  or  the  cash  difference  between  the  ration 
drawn  and  the  amount  allowed  is  turned  over  to  the 
surgeon  in  charge  of  the  hospital,  to  be  expended  by 
him  for  the  benefit  of  the  patients,  either  for  luxuries, 
comforts,  or  articles  of  hospital  furniture — the  pur- 
chases not  being  restricted  to  articles  of  subsistence. 
This  fund  is  ample  to  meet  every  want  of  the  sick. 

For  the  very  sick,  the  dietary  orders  being  indi- 
vidual, no  difficulty  exists  in  prescribing  for  them. 
It  is  for  those  drawing  ordinary  fare,  and  who  re- 
quire to  be  guided  by  seme  fixed  rule,  that  diet  tables 
are  found  so  useful  in  diminishing  the  daily  routine 
duties  of  the  surgeon.  This  diet  list  is  carefully 
"compiled  by  the  surgeon  in  charge  of  the  hospital, 
and  contains  those  articles  of  diet  which  would  be 
best  suited  to  the  many,  and  which  the  markets  at 
the  same  time  can  readily  furnish.  As  this  is  a  sine 
qua  non  in  a  hospital,  and  gives  much  trouble  in  its 
preparation,  1  have  here  introduced,  as  a  guide,  a  diet 
table,  which  might  be  useful  as  a  basis  in  preparing 
one  for  individual  hospital  service. 

Two  drachms  of  tea  or  four  of  coffee,  with  ono 
ounce  of  sugar  and  one-eighth  pint  of  milk,  to  be 
allowed  to  each  patient  for  one  pint  of  tea  or  coffee, 
morning  and  evening. 

The  beef  or  mutton,  for  full  or  half  diet,  is  to  be 

made  into  soup,  with  vegetables,  and  cue  pint  ofsoup 

given   to  each   patient,  with   his  proportion  of  the 

boiled   meat.     The   vegetables,   :i-   rice,  potatoes,  or 

i 


llo-TMrAI.    DIET. 


.  are  frequently  changed,  to  give  variety  to  the 
meal. 


/'.'.  I  for   /'■ilirntx  in  the   Military   [fcpitiil. 


I  I    I  I.    I'llCT. 


niKT. 


Bread 1  lb.  Bread |  lb.  Bread i  lb. 

Beef  or  mutton . .  .*  lb.  Beef  or  mutton....  j  lb.  Tea J  or.. 

Potatoes,  or") 1  lb.  Potatoes,  or") I  lb. .Sugar 2  os. 

Beans,  or  . .  >  . . .  .4  oe.  Beans,   or.".  > I  os.  Milk  fur  tea. . .  .1  "/.. 

Rice J  ...  .4  ob.  Rice J 4  os   Corn  meal 1  lb. 

Vegefesfor  soup.  .4  os.  Veget'es  for  soup.  .4  oz.  Milk 1  pt. 

Salt 1  oc.  Sail 1  os. 

Tea,  or  )    i  os.  Tea i  os 

Coffee,  j   1  os.  Sugar 2  os 

SugaT 2  oz.  Milk  for  tea 1  os 

MiUf  for  tea 1  os    Molasses 1  07. 

1   os.  Corn  meal    1    lb 

Corn  meal 1    Up.  Sou] i   pt    

Soup 1     pt. 

Veal,  fowls,  or  bacon;    Snob  quantities,  in  lieu  of  beef  and  mutton, 
aa  tbo  medical  officer  may  prescribe. 
Wine,  wbi.-k'-v.  porter,  or  ale,  at  the  surgeon's  discretion. 


The   diet    would    be    distributed    in    the    following 
order : 


Brkakfast. 


Dinner. . . 


!i»pi>kr.  . . .  < 


Bread 4  lb. 

Tea  or  ooffec . .  1  pt 
Hominy  &  molasses. 


Bread *  lb 

Tea 1  pt 

1  loniiny  &  molasses. 


Beef  or  mutton. J  lb.   Beef  or  mutton.}  lb. 

Son  1 1  pt.  Soup 1  pt 

Bread h  lb.  Bread |  lb. 

Beana,potat's  or  rice  Beans,potat'a  or  rice 

Bread i  lb.  Bread h  lb. 

Tea  or  coffee.  ..1  pt.  Toa 1  pt. 


Bread.. ..J  lb. 

Tea 1  pt. 

Gruel. . .  -i  pt. 


(irucl. 
Milk.. 


.  1  pt. 
.1  pt. 


Bread. ...J  lb. 

Tea 1  pt. 

Gruel.  •  •  •  i  pt. 


The  attending  surgeon  adds  what  he   wishes  to  the 
above  diet,  to  suit  any  individual  case  in  the  hospital. 


C  II  A  P  T  E  R    III. 

Mbdicai,  Service  of  thk  Abmt— Tub  Mkans  of  Transporting  the 
Sick  and  Wounded — Hand-Litters — Horse-Litters — Amui'lanck 
Wagons,  inc. 

The  transportation  of  the  sick  and  wounded  of  an 
army  is  always  a  matter  of  difficulty,  and  is  not  un- 
commonly the  indirect  cause  of  an  increased  mortality. 
The  injury  inflicted  upon  a  wounded  man  by  a  trans- 
portation of  even  a  few  hours  over  bad  roads,  and  in 
unsuitable  vefucles,  is  incalculable.  Wounds  which 
had  been  doing  well  prior  to  the  move,  take  on  at 
onco  an  unhealthy  appearance:  some  slough,  ery- 
sipelas or  mortification  shows  itself  in  others,  while 
all  feel  more  or  less  its  malignant,  injurious  influence, 
even  with  the  best  transports,  and  under  the  most  fa- 
vorable circumstances.  The  jolting  of  a  broken  limb 
for  three  or  four  hours  over  a  rough  road,  is  indescrib- 
able torture.  The  prostration  and  exhaustion  de- 
picted upon  the  faces  of  the  wounded  after  such  a 
transfer,  explains  at  once  the  problem  why  such  num- 
bers die  during  their  transportation,  and  makes  us 
wonder  how  so  many  escape  with  life,  after  under- 
going such  unutterable  hardships. 

The  transportation  of  the  sick  should  also  be  a 
source  of  anxious  solicitude  on  the  part  of  a  quar- 
termaster whose  humanity  has  not  been  bereft  of  every 
spark  of  sympathy.  H  is  said  that,  in  the  service,  a 
familiarity  with  Buffering  and  privation,  and  the  usual 
demoralising  agents  always  at  work  and  so  widely 
diffused  through   an   army  in  the  field,  destroy  all  the 


100  HAND-LITT1 

finer  feelings  of  a  man,  making  him  nol  only  careless 
•  Inii  callous  i"  the  wants  of  others.  It  is  only 
similarity  of  suffering  that  can  produce  sympathy  in 
feeling.  Could  those  in  the  quartermaster's  depart- 
ment undergo  the  same  treatment  which  falls  t<>  the 
Lot  of  the  sick  and  wounded  daring  transportation, 
would  be  ;i  few  more  comforts  extended  t<>  those 
who  are  periling  their  lives  for  their  count  ry's  Bafety. 

The  following  are  the  usual  modes  of  transporting 
those  wounded  during  a  buttle  : 

LlTTSUS. — Tlie  common  and  best  means  of  moving 
wounded  men,  for  short  distances,  is  upon  litters, 
which  may  be  prepared  in  advance,  or  be  an  impromptu 
manufacture.  In  case  of  necessity,  a  litter  can  be  im- 
provised from  the  blanket  ofa  Boldior.  This  is  doubled 
upon  itself,  a  slit  being  made  through  the  end  corners 
sufficiently  large  to  admit  the  barrel  ofa  musket  ;  one 
musket  is  passed  through  the  fold  of  the  blanket,  an- 
Other  through  the  slits  in  the  ends,  and  a  litter  is 
ready  for  use.  Soldiers'  blankets  are  :it  times  prepared 
for  this  service,  by  having  strong  loops  Bewed  to  the 
corners,  bo  that  when  the  blanket  is  doubled  the  * •  ■  n r 
loops  will  come  on  one  straight  Bide ;  one  musket 
is  passed   through  the  tour  Loops,  the  second  between 

the  folded  blanket.  Where  comrades  from  the  ranks 
are  expected  to  carry  off  the  wounded,  this  is  the  only 
Litter  which  is  of  service,  us  any  two  soldiers  are 
always  prepared  to  act  as  curriers  without  hampering 
themselves  during  the  fight  with  extra  baggage. 
Such  a  litter  is,  however,  very  defective,  as  the  weight 
of  the  patient  sags  the  yielding  blanket  until  it.  nearly 
reach.-  the  ground,  while  the  muskets  arc  pressed  in 
upon  the  haunches  of  the  bearers,  which  renders  it  im- 
possible for  them  to  proceed  with  ease  or  celerity. 


HAND-LITTERS.  101 

A  more  useful  and  equally  simple  litter  or  stretcher 
is  made  of  strong  sacking  or  canvas,  six  foot  four 
inches  long  and  two  feet  wide.  A  broad  hem  is  taken 
up  on  either  side,  through  which  passes  a  stout  pole 
eight  feet  long.  Two  iron  or  steel  rods,  two  feet  long, 
terminating  in  rings  at  the  extremities,  slip  over  the 
ends  of  the  poles  and  form  the  stretchers.  These,  keep 
the  poles  separated  and  prevent  any  sagging  of  the 
litter.  A  shoulder  strap,  with  loops  to  receive  the 
poles,  completes  an  apparatus  which  is  capable  of  car- 
rying off  a  wounded  man  with  all  the  comfort  which 
his  situation  admits.  A  pike-head  attached  to  the  pole 
makes  it  a  formidable  Aveapon  of  defence.  Each  of 
those  who  are  expected  to  transport  the  wounded  is 
armed  with  such  a  pike,  and  carries  one  iron  stretcher 
and  canvas  bottom  strapped  upon  his  knapsack.  Any 
two  of  these  carriers  meeting  together  will  be  enabled, 
in  a  few  minutes,  to  equip  an  efficient  litter.  When 
laid  on  the  litter,  the  soldier's  knapsack  is  under  his 
head  as  a  pillow,  and  his  musket  lies  alongside  of  him, 
or  may  be  hung  from  the  side  of  the  litter  by  loops 
placed  there  for  that  purpose.  This  is  the  best  litter 
that  can  be  devised  for  an  army  in  which  there  is 
deficient  transportation,  and  in  our  service  should 
be  generally  adopted,  as  they  will  be  borno  by  the 
ambulance  corps  without  complaint,  and  will  be 
always  at  hand  when  required. 

A  framed  litter  is  one  of  very  questionable  utility,  as 
it  is  a  very  bulky  article,  and  ono  easily  broken, 
so  that  usually,  after  a  long  march,  very  few  of  them 
are  tit  for  service. 

The  litters  used  in  the  Confederate  service,  as  seen  in 
plate  1,  are  composed  of  canvas,  t  wenty-four  inches 
wide,  securely  tacked  to  two  horizontal  bars  eight 
feet   long;  the  Stretchers,  which  slip  over  the  handles, 


DAND-LITTEB8. 

and  to  which  the  canvas  is  temporarily  secured  by 
straps,  being  a  square  bar  of  wood,  with  a  loop  <>t' 
band  iron  over  the  omls,  forming  the  eyes  through 
which  pass  the  handles.  The-''  are  convenient,  as 
they  fold  in  a  small  compass  for  transportation.  A- 
the  stretching  apparatus,  which  i-  loose,  is  sometimes 
lost  or  misplaced,  which  renders  the  litter  us< 
it  may  be  secured  to  the  side  bars  by  substituting  for 
the  iron  loop  hinges  or  hooks.  A  steel  rod,  folding 
upon  it-  centre,  can  he  so  connected  to  the  side-  of  the 

litter  beneath  the  sacking  as  t<>  unfold  with  the  litter, 
and  ad  as  a  stretcher  without  tear  of  becoming 
detached.  Short  folding  legs,  working  upon  an  iron 
ptVOt,  and  kept  in  place  by  a  Btop-block  or  an  iron 
hook,  complete  the  apparatus.  In  the  Confederate 
service  (en  of  these  form  the  quota  of  each  regiment 

in    the   tield. 

'I'h  esc  framed  litter-  have  been  a  source  of  constant 
annoyance  to  regimental  Burgoons.  To  he  made 
Btrong  enough  to  bear  tin-  ordinary  usage  for  which 
they  are  intended,  they  are  necessarily  heavy,  and 
therefore  a  cause  of  complaint  with  the  ambulance 
corp-.  whose  duty  it  is  to  bear  them.  Our  wagon 
transportation  having  been  always  deficient,  with  no 
room  for  litter-  in  the  hospital  wagon  or  ambulances, 
the  litter-bearers,  to  relieve  themselves  of  tin'  weight 
of  a  litter,  accidentally  break  tin'  woodwork  against  a 
rocb  or  tree,  and  then  rip  oil'  the  sacking,  which  they 
afterward  use  as  a  litter  by  cutting  holes  in  tin-  four 
corners   ami    using   two  poles  cut   by  the    roadside, 

when  they  are  called  upon  to  convey  wounded  men. 
Others  throw  away  the  litters  as  so m  as  they  are 
annoyed  by  the  weight.  Unless  the  infirmary  corps 
are  made  responsible  for  the  litter-  which  are  put 
in  their  possession,  and  be  made  to  pay  for  any  loss  or 


IIANP-LTTTEItS.  103 

injury  sustained,  litters  will  always  be  deficient  in  our 
army. 

Another  objection  to  the  framed  litter,  especially 
with  feet,  is  that  they  are  often  used  as  beds  and 
lounges  for  officers,  although  this  application  is 
expressly  prohibited, and  while  thus  used  are  frequent- 
ly broken  by  persons  tin-owing  themselves  upon  them, 
or  sitting  upon  one  of  the  sides.  As  the  feet  are 
seldom  required,  it  is  an  improvement  to  omit  them  in 
the  construction  of  litters. 

Williamson,  in  his  Notes  on  the  Wounded  from  the 
Mutiny  in  India,  published  in  1859,  has,  in  the  appen- 
dix, a  plate  and  description  of  a  dooley — a  kind  of  litter 
used  for  the  conveyance  of  the  sick  and  wounded 
in  India.  In  the  field  service  it  forms  the  patient's 
bed  as  well  as  means  of  conveyance,  from  the  time  of 
his  being  wounded  until  he  is  cither  cured  or  dies. 
It  consists  of  a  framework,  resembling  a  bedstead 
in  miniature,  six  and  a  half  b}'  two  feet,  with  light 
posts,  which  run  below  the  bed  six  inches.  This 
is  slang  by  two  ropes  placed  on  either  side  from 
the  bead  and  foot,  and  running  up  triangularly — the 
pole  upon  which  the  litter  is  supported  passing 
through  the  apex  of  these  two  triangles.  A  tarpaulin 
cover,  with  side  curtains,  excludes  the  sunlight  and 
gives  privacy  to  the  wounded.  When  the  bearers 
arrive  at  the  encampment,  they  run  the  dooley  into 
the  hospital  tent,  take  out  the  pole  with  the  tarpaulin 
covering  and  curtains,  with  which  they  make  their 
tent,  leaving  the  patient  comfortable  in  his  bed. 
These  wore  found  to  answer  admirably  in  the  Crimea, 

where  they  were  used  to  a  limited  extent.      This  is  the 

comfortable  conveyance  tor  a  sick  or  wounded 
.;.,  and  it >  introduction  generally  into  the  English 
service  ha-  been  strongly  recommended. 


1 1 1  (  BOH  B8. 

Horsb-Litteus. — Ni'.xt  to  band-litters  for  the  trans- 
portation of  wounded  men  are  horse-litters,  made 
three  feet  wide,  with  poles  sixtoon  feet  long,  folding  in 
the  middle  for  convenience  of  transportation.  Eon 
or  males  take  the  place  of  men — the  poles  acting 
as  shafts,  and  Bupported  by  back-strapa  or  by  a  saddlo 
with  t  ti lt-.  as  in  ordinary  harness.  Bach  horse-litter 
earrios  two  persons.  When  the  mules  are  led  by  men 
well  trained  for  this  duty,  transportation  by  this 
means  is  well  suited  to  the  comfort  of  the  wounded  ; 
but  if  the  muleteers  are  raw  hands,  who,  holding  tho 
mule  by  the  head,  attempl  to  lead  it.  instead  of  allow- 
ing it  to  pick  its  own  way.  the  joltings  and  sudden  jars 
make  thi-<  litter  anything  bul  a  bed  <»t  down. 

The  French  use  what  is  called  a  cacolet,  a  kind 
of  arm-chair,  which  is  suspended  <>ii  each  side  of  a 
pack-saddlo  n]>  m  a  mulo.  'Tin.'  mechanism  of  this 
ebair  is  so  arranged  that  it  can  be  unfolded,  so  as  to  bo 
converted  into  a  bed  or  a  litter.  It  offers  either  a 
comfortable  seal  for  tho  trivially  wounded,  or  a  bed  for 
the  moro  sorious;  and  each  mule  can  thus  carry 
two  men  comfortably  from  tin-  field  to  tho  infirmary. 
In  hilly  countries,  over  bad,  rough  roads,  this  is  found 
:i  much  bettor  conveyance  than  vehicles. 

Tin'  two  and  four-wheeled  carriage  or  ambulanct  </•■/</- 
ons,  which  have  been  adopted  in  every  civilized  army, 
are  considered  indispensable  for  field  service,  and  for 
the  transportation  <>f  the  wounded.  Both  are  so  ar- 
ranged as  to  allow  of  the  woundod  boing  carried  ly- 
ing, reclining,  or  sitting.  The,  omnibus  is  the  most,  ex- 
pedition*) means  of  removing  those  slightly  wounded, 
who  arc  no!  able  to  walk  from  the  field.  Whore  the 
roads  arc  good,  in  an  open  ion n try,  this  vehicle  should 
not  i"-  overlooked.  The  four-wheeled  spring  ambu- 
lance wagon  is  the  most  comfortable  for  the  wounded, 
and  also  the  most  useful  for  the  servico. 


AMBULANCE    WAGON.  105 

In  the  Confederate  service  the  four-wheeled  spring 
wagon,  as  seen  in  plate  1,  is  the  one  in  general  use, 
although  the  two-wheeled  wagon  is  also  used.  It  con- 
sists of  a  box  body,  three  and  a  half  feet  wide  and 
seven  and  a  half  feet  long,  placed  upon  three  springs. 
Two  stuffed  seats  run  the  entire  length  of  the  wagon; 
and  the  drop  from  this,  which  is  attached  to  the  seat 
by  hinges,  and  is  equally  cushioned,  can  be  elevated 
horizontally,  and  supported  by  feet,  which,  with  the 
scat,  will  form  a  continuous  bed  over  the  entire  wag- 
on. Such  wagons  will  transport  two  men  lying,  or 
from  ten  to  twelve  sitting — the  inmates  being  protect- 
ed from  the  sun  and  rain  by  a  cloth  cover  and  side 
curtains,  supported  upon  a  frame.  Two  five-gallon 
kegs,  secured  under  the  bottom  of  the  wagon,  carry 
water  for  the  sick  and  wounded. 

The  Coolidge,  two-wheeled  ambulance  wagon,  which 
is  in  use  in  the  Federal  army,  is  a  very  ingenious  but 
complicated  arrangement,  and  is  liable  to  be  broken 
by  the  ordinary  uses  of  the  service.  In  these,  instead 
of  seats,  there  arc  two  frames,  which  can  be  used  as 
litters.  These  run  upon  rollers  on  the  bottom  of  the 
wagon.  The  frames  have  folding  legs  and  sliding 
handles,  which  occupy  no  available  room.  Upon  the 
t<>])  of  the  litter  is  a  frame,  divided  into  three  portions, 
folding  in  such  a  way  that  the  head  of  a  wounded  man 
can  be  elevated  nearly  to  a  sitting  posture,  or  the  leg 
equally  elevated,  should  the  peculiarity  of  the  wound 
require  it.  A  partition  through  the  body  of  the  wag* 
on  separates  the  t  wo  patients  which  the  interior  of  the 
wagon  accommodates.  Under  the  driver's  seat  is  a 
box,  which  can  be  used  as  a  medicine-chest.  This  ve- 
hicle is  intended  for  one  horse  in  shafts,  "i*  two  in 
tandem. 

When  transportation  is  abundant,  the  Confederate 


106  A.MBULANOB    WAGON.  ^^^ 

•  allows,  for  every  command  of  Loss  than  three 
companies,  one  two-wheeled  transport  cart  for  bospi- 

tal  supplies,  and  t"  each  company  one  two-wheeled 
ambulance  carriage.  For  commands  <>t'  more  than 
three  or  less  than  five  companies,  two  two-wheeled 
transport  run-.,  and  to  each  company  one  two-wheel- 
ed ambulance  carriage.  For  a  battalion  of  five  com- 
panies, one  four-wheeled  and  five  two-wheeled  ambu- 
lance carriages,  and  two  two-wheeled  transport  carts; 
and  foreach  additional  company,  less  than  ten,  one  two- 
wheeled  transport  cart.  For  a  regiment,  two  four* 
wboeled  ambulance  wagons,  ten  two-wheeled  ambu- 
lance wagons,  and  four  two-wheeled  transport  carts. 
This  number,  however,  has  never  been  received  by  a 
regiment,  and  often  one  wagon  for  transporting  the 
hospital  apparatus,  ami  <>no  four-wheeled  (rarely  two) 
ambulance  wagons  complete  the  actual  supply  to  regi- 
ment -  in  tin-  field. 

Where  there  are  many  sick  to  he  moved  from  camp 
to  a  general  hospital,  should  the  transportation  in 
ambulance  wagons  be  deficient,  advantage  is  takm  of 
tli.-  return  of  empty  eommissary  wagons  to  the  rear 
t'.  Bend  oil'  the  sick,  ami  vehicles  <.f  every  description 
may  be  impressed  lor  this  Bpecial  service. 


C  II  A  P  T  E  11   I  V. 

Medical  and  Surgical  Staff  of  Armies — Tub  Medical  organiza- 
tion in  the  Confederate  service;  English  service;  French 
service  ;  Prvssian  service — Infirmary  Corps,  or  litter-car- 
riers for  transporting  the  wounded  from  the  field — Duties 
of  the  Hospital  Surgeon — Duties  of  the  Regimental  Surgeons 
and  Assistants  in  camp  and  on  the  rattle-field — Medical  sup- 
plies allowed  in  the  field — Preparations  needed  on  the  kve 
of  a  battle — Positions  occupied  by  the  Medical  Staff  during 
TnE  fight. 

Medical  Service  of  the  Army. — Tho  medical  staff 
of  an  army  is  selected  with  care  by  an  examining 
board,  whose  rigid  inquiries  into  the  literary  and  pro- 
fessional attainments,  as  well  as  into  the  moral  and 
physical  condition  of  the  applicant,  keeps  the  staff 
purged  of  inferior  men,  and  forms  a  body  of  scientific 
Investigators  whose  efficienc}-  will  compare  favorably 
with  the  profession  of  any  country. 

During  war,  the  medical  department  increases  part 
passu  with  the  army.  These  appointments  should  bo 
made  with  a  lull  knowledge  of  the  weighty  responsi- 
bilities attached  to  the  medical  stall',  without  whose 
constant  solicitude  for  the  health  and  well-being  of  the 
troops  committed  to  their  care,  the  effective  strength 
of  an  army  will  be  materially  reduced.  With  a  view 
to  ensure,  at  all  times,  the  most  active  and  efficient 
treatment  for  the  sick  in  the  arm}',  ami  particularly 
during  active  service,  it  is  not  only  essential  thai  the 
medical  officers  should  be  men  of  ability  and  of  high 
professional  qualifications,  but  that  they  should  pos- 
sess physical  energy  adequate  to  their  arduous  duties. 


I  08  MEDICAL    st  \i  r    OF    AN    A.BMT. 

It  is  a  common  impression  that  Burgeons  alone  arc 
wanted  in  the  army,  under  the  erroneous  belief  that 
tho  only  risks  to  which  troops  arc  exposed  are  the 
bullets  of  tho  enemy.  As  we  have  elsewhere  shown 
that  for  one  killed  by  the  enemy  at  least  eight  die  of 
disease  contracted  in  camp,  this  will  be  sufficient  prool 
that  the  physician  must  be  even  more  important  than 
the  surgeon.  Long  before  the  first  shot  is  fired,  there 
arc  diseases  to  contend  against.  Whether  in  camp 
or  on  the  march,  diseases  are  constantly  developing 
themselves.  Surgery  has  its  periods,  and  although 
hospitals  may  he  filled  with  wounded  men  immedi- 
ately alter  a  fight,  beds  are  soon  vacated  t<>  be  refilled 

by   the  eVer-COming  sick.      Some  of  the  wounded  die,  a 

large  proportion  rapidly  get  well  and  are  discharged, 

and  the  protracted  cases  are  sent  home  to  recruitj 
hut  these  leave  no  vacancies,  as  their  places  are  im- 
mediately tilled  by  the  sick. 

Tii.'  advantages  of  having  an  experienced  surgical 
stall' in  the  field,  and  the  influence  which  it  can  exert 
on  the  vicissitudes  of  war,  must  he  acknowledged  by 
e\«ry  thinking  man.  Vet,  medical  advice  is  seldom 
asked  or  listened  to  by  those  in  command,  so  lone;  as 
Buffering  and  death  are  not  cruelly  felt.  The  proper 
understanding  between  the  surgical  and  military  staff 
of  an  army,  with  concert  of  action,  will  Bave  many  a 
soldier,  who  would  otherwise  h.-<"  or  compromise  his 
lite,  so  valuable  to  the  country  in  time  of  need. 

In  the  Confederate  Bervico  but  two  grades  in  the 
medical  stall' are  recognized — surgeons  and  assistant 
Burgeons,  with  the  respective  assimilative  rank  of 
major  and  captain.  The  head  <>t  the  medical  depart? 
menl  is  presided  over  by  a  surgeon-general,  with  tho 
rank  of  lieiitenant-eoloncl  of  cavalry,  which  is  the 
highest  grade  in  the  service,  ami  which  position  is  held 


MEDICAL    STAFF    OF    AN    ARMY.  109 

by  seniority  of  commission.  There  are  other  merito- 
rious positions,  viz  :  of  medical  directors  and  inspect- 
ors for  field  and  hospitals,  and  medical  purveyors  of 
the  army,  which  are  appointments  hy  the  Burgeon- 
general,  and  are  considered  offices  of  responsibility 
and  trust,  although  without  increased  rank. 

In  the  Confederate  service  each  regiment,  nominally 
of  one  thousand  men,  has  one  surgeon  and  one  as- 
sistant surgeon.  Where  several  regiments  are  united 
into  brigades,  the  oldest  commissioned  surgeon  in  tho 
brigade  assumes  the  position  of  brigade  surgeon,  who, 
however,  is  not  relieved  from  regimental  duty.  When 
brigades  are  thrown  together  into  divisions,  the  sur- 
geon upon  the  staff*  of  the  major-general  assumes  the 
position  and  duties  of  division  surgeon.  The  union  of 
several  divisions,  comprising  a  corps  d'armee  under  tho 
command  of  a  lieutenant-general,  has  a  chief  medical 
officer  with  the  title  of  corps  surgeon,  or  medical  di- 
rector of  the  corps;  and  when  two  or  more  corps 
d'armee.  form  an  army,  the  medical  affairs  of  such  a 
bocly  of  men  is  supervised  by.  a  medical  director  rec- 
ommended b}r  the  surgeon-general,  and  appointed 
by  the  Secretary  of  War,  at  the  solicitation  of  the 
general  in  command. 

In  times  of  peace,  two  medical  regimental  officers  are 
found  scared}*  sufficient  to  attend  to  the  sick;  while, 
in  times  of  epidemics  or  war,  they  are  incompetent  to 
offer  that  assistance  which  the  sick  and  wounded 
require.  Many  a  life  has  been  sacrifice^  to  procrasti- 
nation. Upon  the  first  and  immediate  attention  to  tho 
wounded  on  the  battle-field  depends,  in  a  great  meas- 
ure, the  success  of  treatment  ;  and  in  any  encounter 
which  deserves  the  name  of  a  battle,  the  wounded 
must  necessarily  be  neglected  by  this  deficient  medical 
staff 


11"  MEDICAL    BTAFF   OJ    TIIE    ENGLISH    ARMY. 

Our  large  experience  has  proved  the  inefficiency  of 
our  regimental  medical  staff.  European  experience 
confirmfl  the  observation,  that  two  medical  men  are 
not  sufficient  t<>  take  care  of  the  health  of  a  full  regi- 
ment of  a  thousand  men.  This  was  the  subject 
of  general  comment  in  the  Crimea,  where  the  medical 
stall  were  unanimous  in  the  demand  for  additional 
medical  assistance,  [n  active  Bervice,  every  full  regi- 
menl  should  have  at  least  one  surgeon  and  two  assist- 
ant Burgeons,  these  differing  only  in  rank,  their  duties 
being  similar.  Bosides  the  regular  regimental  Bur- 
geons, there  is  in  the  Confederate  service  a  medical 
corps  to  take  charge  of  military  hospitals,  while  regi- 
mental officers  accompany  their  commands. 

In  the  English  service,  the  medical  department  is 
composed  of  regimental  Burgeons,  with  their  assist- 
ants, staff  surgeons  of  the  first  and  second  class,  and 
medical  inspectors.  The  staff  surgeons  of  the  first 
class  rank  the  regimental  surgeons,  and,  with  their 
assistants,  either  take  charge  of  military  hospitals,  or 
act  as  medical  supervisors  for  a  brigado,  composed  of 
three  or  more  regimonts.  Tho  assistant  staff  sur- 
geon holds  the  same  rank  as  the  regimental  Burgeon. 
When  many  brigades  are  collected  into  a  division,  a 
stall'  surgeon  of  long  service  is  appointed  to  direct 

the   medical    and    surgical   affairs  of  the  division  ;   and 

when  a  large  force,  consisting  of  several  divisions, 
with  their  respective  generals  and  physicians,  is 
brought  into  the  field  for  actual  Bervice,  and  placed 
under  a  general-in-ohief,  a  dical  stall'  officer,  bear- 
ing the  title  of  inspector-general,  is  appointed  to  su- 
perintend  ami  COUCentratO  all    the    movements  of   tho 

lical  department  of  the  army.     The  medical  de- 
partment takes  the  military,  thereforo,  as  its  model. 
In   the    French  army  a  somewhat   similar  organ iza- 


MEDICAL    STAFF    OF    THE    PRUSSIAN    ARMY.  Ill 

tion  is  found.  Besides  Burgeons  and  assistant  Bur- 
geons attached  to  regiments,  the  military  hospital 
staff,  which  is  a  very  numerous  one,  consists  of  medi- 
cal inspectors  or  head  Burgeons  of  infirmaries,  stall* 
surgeons  of  the  first  class,  Avith  senior  and  junior 
assistants — the  number  detailed  for  special  hospital 
duty  depending  upon  the  size  of  the  institution  and 
the  number  of  its  inmates. 

The  most  thorough  medical  organization  in  Europe 
'belongs  to  the  Prussicui  service,  and  is  composed  as 
follows : 

Bacb  battalion  of  one  thousand  men  lias  a  surgeon 
and  assistant  surgeon,  who  are  thoroughly  instructed 
in  the  duties  which  they  are  expected  to  perform. 
Beside  these  there  is,  to  every  corps  d'armee  of  thirty 
thousand  men,  a  staff  of  forty  surgeons,  who,  in  time 
of  war,  take  charge  of  the  general  military  hospitals 
opened  for  the  reception  of  the  sick  and  wounded. 
This  division  has  also  attached  to  its  medical  depart- 
ment three  infirmary  staffs  for  light  field  service, 
composed  of  eleven  surgeons  each.  These  act  as  a 
reserve  on  the  battle-field,  opening  field  infirmaries 
which  follow  the  troops,  and  give  the  first  aid  and 
dressing  to  the  wounded.  This  gives  a  proportion  of 
nine  surgeons  to  every  two  thousand  men;  and.  not- 
withstanding this  large  number,  there  arc  periods 
when  even  a  larger  number  of  Burgeons  would  not  bo 
sufficiently  numerous  to  give  proper  and  immediate 
assistance  to  the  wounded. 

In  most  European  armies  the  dispensing  of  medi- 
cines is  performed  by  apothecaries,  who  complete  the 
medical  organization.  In  the  English  service  the 
siatanl  Burgeon  or  hospital  steward  acts  as  apothe- 
cary. In  the  Confederate  army,  as  physicians  of 
experience  are  numerous  in   the  ranks,  one  of  these 


I  12  AMBULANCE    CORPS. 

usually  receives  the  appointmont  of  hospital  steward 
in  the  field,  or  apothecary,  with  the  rank  of  hospital 
steward  in  the  general  hospitals,  and  upon  him  de- 
volves th<-  preparation  and  dispensing  of  drugs. 

In  recenl  European  campaigns  a  very  important 
addition  has  been  made  to  the  surgical  service.  It  is 
the  ambulance  corps,  or  carriers  of  the  wounded.  Here- 
tofore, when  men  were  shot  down  from  the  rank's, 
they  were  home  to  the  haek  hy  their  eomradesdn- 
arms,  who  transported  them  to  the  field  infirmaries, 
where  the  surgeons  attended  to  their  wounds.  Al- 
though a  most  praiseworthy  act  of  devotion  to  a  fall- 
en friend,  it  was  often  called  for  when  help  could 
Least  l'e  Bpared,  as  the  taking  away  of  so  many  fight- 
ing men  from  the  ranks  enfeehlcs  the  strength  of  the 
command,  ami  diverts  the  attention  of  the  soldiers,  if 
its  demoralizing  effect  does  not  break  up  the  corps* 
It  is  also  well  known  that,  if  any  from  the  ranks  are 
drawn  from  the  fight  to  carry  off  the  wounded,  they 
never  return  until  the  light  is  over,  and  thus  three 
are  lost  to  the  company  instead  of  the  one  wounded. 
Besides,  with  the  very  best  in  tent  ions,  these  comrades 

are  not  instructed  how  to  carry  the  wounded  so  that 
(ley  should  Buffer  least  detriment,  and  the  final  result 
can  not  he  hut   injurious  to  the  wounded.      The  amlui- 

lance  corps,  which  now  forma  a  very  essential  part  of 
every  army,  is  a  regularly  organized  body  of  nun, 
carefully  selected  for  their  strength  and  courage,  who 
are  taught  how  to  carry  Wounded  men.  These  prac- 
ticed hands  are  under  military  discipline,  commanded 
hy  officers  whose  duty  it  is  to  see  that  (he  wounded 
arc  promptly  and  carefully  removed  from  the  places 
where  t  hey  fall  tot  he  infirmai 

The  assistant  surgeon  of  a  regiment  accompanies 
i  he    ambulance    corps     to  superintend     the    judicious 


DUTIES    OF   AMBULANCE   CORPS.  113 

transportation  of  the  wounded.  While  thus  employed 
he  is  only  expected  to  offer  temporary  assistance. 
Should  there  be  fearful  hemorrhage,  he  may  apply  a 
tourniquet,  or  show  the  assistants  how  to  compress, 
effectually,  a  bleeding  vessel.  He  arranges  broken 
limbs  so  as  to  have  the  wounded  man  conveyed  with 
the  greatest  degree  of  comfort,  and  gives,  perhaps,  a 
dose  of  morphine  when  much  suffering  is  felt,  but  as 
long  as  active  fighting  is  going  on  he  has  no  time  to 
offer  more  than  this  temporary  assistance. 

This  ambulance  corps,  with  litters,  ambulance  wag- 
ons, pack-horses,  and  all  other  facilities  for  transport- 
ing wounded  men.  should  be  in  the  advance,  imme- 
diately behind  the  line  of  battle.  Their  post  is  one 
of  great  risk  as  well  as  of  heavy  responsibility )  for, 
not  unfrequcntly,  they  lose  their  lives  in  accomplishing 
their  benevolent  task.  Both  humanity,  civilization, 
and  economy  dictate  that  such  a  corps  should  be 
appended  to  every  army  in  the  field.  When  not 
wanted  on  the  battle-field,  experience  makes  them 
Careful  nurses  for  the  sick  and  wounded. 

The  ambulance  corps,  as  connected  with  each 
brigade  in  the  Confederate  service,  is  composed  of  two 
men  from  each  Company  of  a  hundred  men,  selected  for 
braveiy,  strength,  endurance,  and  good  character — 
the  object  being  t<>  make  this  corps  as  efficient  as 
possible.  When  suitable  in  other  respects,  physicians 
or  students  of  medicine  found  in  the  ranks,  are 
Bolected.  The  duties  of  the  ambulance  corps  are  very 
trving  requiring  undaunted  courage  as  well  as  great 
endurance,  to  enable  them  to  work  uninterruptedly 
under  fire,  following  closely  the  line  <>f  battle,  with 
their  lives  exposed  at  every  moment  from  the  missiles 
oftheenemy,andyet  unarmed  and  without  excitement. 
This  brigade  ambulance  corps  is  under  the  command 


114     frknch   ORGANIZATION   OF   AMBULANCE   CORPS. 

of  .1  lieutenant.  The  men.  selected  from  each  regi- 
ment, two  from  every  hundred  men,  are  in  charge 
of  a  sergeant,  who  is  frequently  a  medical  man — the 
conscript  law  n<>t  exempting  physicians  under  thirty- 
five  years  of  age  from  military  servic* — and  patriotism 
having  induced  many  of  much  more  extended  practice 
to  take  the  field.  The  members  of  this  corps  are 
designated  by  wearing  around  their  eaps  a  red  hand. 
with  (tmbxdance  corps  printed  in  conspicuous  white 
letters.  Each  carries  a  large  canteen  tilled  with 
water.  Their  duties  are  to  follow  their  regiments  into 
the  fight,  accompanied  by  the  assistant  surgeon,  and 
convey  to  a  place  of  safety  such  as  art'  shut  down  ami 
too  severely  wounded  to  get  oil'  the  field  without 
a-^istance.  When  the  army  is  in  motion,  the  infirmary 
corps  marches  in  the  rear  of  its  regiment,  hearing  the 
five  litters  now  allowed  to  each  regimental  corps. 
When  in  camp,  they  are  employed  about  the  hospital 
a-  attendants  upon  the  sick.  In  many  regiments  they 
are  never  railed  upon  for  guard  duty  during  an  active 
campaign,  and  are  allowed  all  the  privileges  granted 
the,  color-guard.  Winn  an  army  goes  into  permanent 
camp  they  are  returned  to  the  ranks,  to  resume  their 
duties  as  an  ambulance  corps  as  soon  as  the  campaign 
is  resumed — the  men  who  have  been  instructed  in  this 
duty  being  continued  in  it. 

The  French  organization,*  which  may  serve  as  a 
model  for  the  formation  of  a  hospital  corps,  is  as 
follows:  One  captain,  one  subaltern,  one  sergeant- 
major,  one  pay  sergeant.  live  sergeants,  or  upper  ward- 
masters  when  in  hospital,  ten  corporals  or  under  ward- 
mast  ers,  two  buglers  (indispensable  for  sounding  halts 
ami  advance  in  the  transport  of  the  wounded  ),  ninety- 


•Artielc  Ambulance,  Co  lopcdia  of  Practical  Surgery. 


MEDICAL    STAFF    IN    PRUSSIAN    ARMY.  115 

six  privates  or  orderlies,  one  tailor,  one  shoemaker,  ono 
cutler  (a  most  useful  artisan  to  keep  surgical  in- 
struments in  repair),  one  carpenter,  lour  cooks. 
When  employed  in  hospital,  these  are  distributed 
in  the  proportion  of  one  ward-master  for  every 
hundred  patients,  and  one  orderly  for  every  twelve. 
The  wagons  and  cars  will  also  be  under  the  command 
of  their  proper  officers )  non-commissioned  officers, 
with  wheelwright,  farriers,  saddlers,  etc.,  are  also 
to  be  attached  to  the  corps.  When  on  a  march,  should 
there  be  a  deficiency  of  transport  wagons,  the  ambu- 
lance wagons  carry  the  hospital  stores,  also  the  packs 
of  weak  men  not  requiring  transportation  ;  they  also 
pick  up  such  men  as  are  not  able  to  proceed  with 
their  companies,  or  those  who  are  compelled  to 
fall  out  of  the  ranks  from  indisposition.  When  troops 
on  a  march  arrive  at  a  place  where  good  water 
can  be  obtained,  the  hospital  corps  should  fill  their 
canteens  for  the  use  of  the  sick.  When  the  troop? 
are  bivouacked,  the  hospital  corps  should  be  employed 
in  throwing  up  huts,  or  in  establishing  temporary 
hospitals  in  any  adjoining  buildings,  and  in  preparing 
some  light  food  for  the  sick  which  they  have  brought 
in. 

The  following  is  the  course  pursued  l>y  (he  Prussian 
medical  corps  of  a  division  of  thirty  thousand  men  when 
going  into  /><ittle:  The  reserve  corps  of  forty  surgeons 
establish  a  general  hospital  at  some  sale  and  con- 
venient point,  four  or  five  miles  from  the  battle-field. 
Here  all  the  appliances  aro  concentrated  tor  giving 
proper  attention  to  the  injured}  and  mosl  of  t h .• 
serious  and  tedious  operations  are  to  he  performed, 
under  judicious  consultation.  As  this  is  the  resting? 
place  from  the  field,  accommodations  musl  he  ample; 


116  MEDICAL   STAFF    IN    PRUSSIAN    ARMY. 

ry  facility  for  treating  successfully  the  seriously 
wounded  must,  therefore,  be  found,  and  all  hospital 
stores  should  bo  concentrated  at  this  hospital. 

Directly  behind  the  line  of  battle,  and  movable  with 
it.  are  placed  the  light  field  infirmaries,  with  their 
special  stalls.  They  arc  the  way-stations  for  medical 
service,  as  all  the  wounded  pass  through  these  on 
their  way  to  the  general  hospital.  At  these  field  infirm- 
aries the  wounded  receive  the  first  thorough  exami- 
nation, and  many  operations  deemed  imperative  are 
here  performed.  All  wounds  are  here  cleansed,  foreign 
bodies  of  every  kind  extracted,  hemorrhage  controlled, 
and  the  first  proper  dressing  applied.  As  the  wound- 
ed are  brought  to  this  point  as  they  are  shot  down, 
their  wounds  have  undergone  but  little  change;  the 
system  is  still  suffering  from  a  certain  amount  of  ner- 
vous -hock,  which  makes  it  the  proper  time  for  effecting 
a  thorough  examination  without  giving  pain. 

In  these,  as  in  the  general  hospital,  there  is  always 
a  division  of  labor,  and  each  Burgeon,  knowing  his 
duty,  accomplishes  the  greatest  amount  of  work  in  his 
special  department.  The  division  always  recognized^ 
is  the  examiner,  the  operator,  and  the  dresser.  Those 
who  arc  most  skilled  in  these  various  departments  are 
expected  to  give  the  benefit  of  their  skill  and  experi- 
ence tO  the  wounded.  .More  importance  is  placed  upon 
these  subdivisions  of  labor  than  we  would,  at  first 
sight,  recognize.  It  is  well  known  that  many  hands 
can  be  efficiently  worked  by  one  head,  and  that  when 
a  surgeon  of  much  experience  and  mature  judgment 
determines  what  course  should  be  pursued,  there  are 
many  competent  to  carry  oul  his  suggestions,  who  were 
not  sufficiently  prepared  to  establish  a  thorough  diag- 
nosis and  foresee  the  probable  issue. 


MEDICAL    STAFF    IN    PRUSSIAN    ARMY.  117 

The  importance  of  examining  a  wound  as  seldom 
as  possible  being  acknowledged,  it  is  easy  to  under- 
stand why  the  most  proficient  surgeons  in  the  service 
should  be  appointed,  as  diagnosticians,  to  examine, 
thoroughly,  the  wounded,  and  determine  upon  a  course 
of  treatment.  In  gunshot  wounds,  above  all  others, 
the  necessity  for  accurate  diagnosis  becomes  impera- 
tive, and  this  first  examination  should  never  be  slurred 
over,  however  urgent  the  demands  upon  the  surgeon's 
time.  Except  in  very  obscure  cases,  a  second  examina- 
tion should  never  be  made,  as  it  always  gives  pain,  in- 
creases irritability,  heightens  inflammation, and  per- 
mits air  to  gain  access  to  the  very  depth  of  the 
wound,  which  is  sure  to  promote  the  decomposition 
of  the  exudates  around  the  wound,  with  its  suppura- 
tive and  sloughing  sequehe.  Many  a  limb  and  life, 
would  be  preserved  were  it  possible  to  limit  the  examina- 
tion of  the  wounded  to  the  field  infirmary.  Let  it  be  re- 
membered that  the  first  examination  is  always  less 
painful  and  dangerous  than  any  subsequent  one.  All 
surgeons  agree  upon  the  success  of  primary  opera- 
tions, when  compared  to  secondary,  after  inflamma- 
tion has  set  in.  How  to  proceed,  or  what  wounds  to 
condemn,  requires  nice  discrimination — heme  the  ne- 
cessity of  devoting  the  talent  and  experience  of  tho 
staff  to  this  very  important  duty. 

In  the  Prussian  service,  the  regimental  surgeons  are 
Concentrated  in  groups  with  their  assistants,  rather 
than  follow  their  respective  regiments  into  the  fire. 
Thus,  much  time  is  saved  and  the  wounded  receive 
more  attention;  and  keeping  them  together  in  this 
way  renders  it  easy  to  command  medical  service 
when  it  may  be  needed  for  any  special  extra  duty. 
This,  of  course,  does  not  prevent  surgeons  being  sent 
to  various  points  of  the  line,  to  assist  the  medical  por- 


ilv  BUDIOAL    STAFF    IN    PRUSSIAN    ARMV. 

tion  of  the  sanitary  corps  in  the  proper  transporta- 
tion of  the  wounded.* 

In  the  same  service,  the  "primary  dressings  for  the 
wounded  are  carried  by  each  soldier,  so  that  all  necessa- 
ry bandages  are  <»n  the  spot,  and  no  time  is  losl  wait- 
ing for  the  bandage  boxes  or  hospital  stores.  The 
genera]  plan  adopted  by  the  entire  army  is  as  follows: 
Every  soldier  carries  a  small  package,  three  inches 
long  and  one  inch  thick,  which  contains  the  following 
articles,  viz:  two  pieces  of  old,  soft,  clean  linen,  nine 
inches  square;  a  piece  of  oiled  silk  or  india-rubber 
tissue,  nine  inches  long  by  five  inches  wide;  a  small 
ball  of  lint  ;  a  bandage  two  and  a  half  yards  long  and 
two  inches  in  width.  One  piece  of  the  linen  is  fold- 
ed double  and  rolled  tightly  over  the  lint,  and  over  this 
the  piece  of  oiled  silk  is  rolled,  the  bandage  rolled 
around  this,  and  the  whole  enveloped  in  the  second 
piece  of  linen,  and  fastened  with  two  pins.  This 
should  be  put  in  a  particular  place  in  the  knapsack, 
where  it  can  always  be  found.  Should  there  be  two 
wounds,  the  oiled  silk  and  cloth  may  be  divided  to 
make  a  double  dressing,  and  one  piece  of  cloth  may 
be  used  by  the  surgeon  as  a  towel.  In  this  small  but 
very  useful  package  is  found  the  requisite  dressings 
for  every  gunshot  wound.  It  saves  the  surgeon  the 
annoyances  and  delays  incidental  to  the  transportation 
of  hospital  stores.  In  the  light  field  infirmaries,  near- 
ly all  the  dressings  of  the  wounded  are  obtained  from 
this  individual  package — the  very  few  extra  articles 
needed  being  furnished  from  the  infirmary  supplies. 

Stromyer,  in  his  surgical  writings  on  the  Schleswig- 
Holstein  war,  speaks  of  the  medical  department  of 
the  army  as  modelled  upon  the  military.     Besides  the 

*Lceffler.     Behandlun;*  dor  Sehusswuiide.    Berlin:  1859. 


MODERN    MISSILES    OF    WAR.  110 

regimental  surgeons,  each  brigade  had  a  brigade  sur- 
geon with  three  assistants.  The  larger  divisions  of 
the  army  were  equally  supplied  with  superior  medical 
officers  ami  staff.  On  the  battle-field  the  surgeons  of 
the  army  established  infirmaries  for  the  immediate 
Care  of  the  wounded,  who  were,  after  the  first  dress- 
ing, sent  into  the  more  permanent  infirmaries. 

Modern  warfare,  in  introducing  arms  of  precision, 
of  immensely  increased  range,  and  perfected  instru- 
ments of  destruction  of  heavy  calibre,  has  created  a 
new  era  in  military  surgery.  The  conical  ball  of  dou- 
ble weight  has  become  the  common  missile,  and  when 
discharged  from  a  rifle  it  flies  with  fearful  velocity. 
Such  balls,  when  traversing  soft  parts,  produce  exten- 
sive destruction,  but  seldom  bury  themselves.  Com- 
paratively few  of  these  are  to  be  extracted  after  a 
battle.  Should  they  impinge  upon  a  bone,  the  split- 
ting and  crushing  is  so  extensive  as  to  necessitate 
more  frequently  amputations  and  resections. 

This  conical  ball  seldom  fails  to  take  the  shortest 
cut  through  a  cavity  or  limb,  and  it  has  at  times  been 
seen  to  pass  through  the  bodies  of  two  men  and  lodge 
in  that  of  a  third.  Rarely  are  they  deflected  from 
their  course,  as  is  the  round  ball,  which  is  turned  by 
every  little  obstacle,  taking  up  a  position  at  striking 
variance  with  any  rule  of  propulsive  forces.  in 
steady  hands  frightful  wounds  are  produced  by  the 
minic  ball,  which  require  all  the  resources  of  surgery 
to  manage  successfully. 

The  following  interesting  table,  taken  from  the 
recent  work  of  ML  Legouest  on  Army  Surgery,  pub- 
lished in  Paris  in  L8Q3,  will  give  an  idea  of  the  rela- 
tive momentum,  and  the  relative  tendency  t<»  do 
mischief,  of  round  and  rifle  balls.  To  exhibit  the 
power   of  penetration    of   balls,  a  target    was   made 


120 


MODERN     MISSILES    OF    WAR. 


tting  up  plank  of  one  inch  in  thickness,  twenty 
inches  apart,  each  numbered  as  in  the  following 
table 


X..i. 

1 
•J 

l 

:t 

■i 

'• 

7 

s 

l 

r.r. 
B 

10 
8 

•  > 

4 

: 

u 

i 

a 

~> 

1 

By  an  examination  of  this  table  it  will  be  seen 
that,  with  the  round  ball  and  smooth  lnu-o.  :it  a  dis- 
tance of  five  hundred  yards,  only  two  shots  perforated 
the  first  plank,  and  one  only,  oul  of  one  hundred  and 
twenty  shot,  traversed  the  second  plank  of  one  inch 
in  thickness;  while  the  majority  of  the  rifled  conical 
shots  perforated  the  first  plank,  n  large  number  the 
second,  third,  fourth,  and  oven  fifth,  while  one  trav- 
ersed the  entire  target  of  eight  planks — which  indi- 
cates, in  a  very  striking  manner,  the  facility  with 
which  rifled  conical  shut  overcome  the  resistance  of 
opposing  bodies,  and  accounts  for  the  straight  course 
which  they  usually  take  through  a  limb,  and  the 
rarity  of  their  inoarcoration  in  the  tissues. 

Jn  making  experiments  for  tho  above  table,  it  was 
also  remarked  that,  for  the  first  two  hundred  yards 
from  the  muzzle  of  the  piece,  tho  round  ball  moved 
with  the  greatest  velocity;  this  was  readily  over- 
come, however,  by  atmospheric  resistance,  and  gravi- 
tation soon  brought  it  to  the  ground.  In  all  instances 
where  a  mark  was  Bhot  at   from  a  distance  of  two 

hundred  yards,  tie-   round    hall  was  the  first  to  strike; 
Over  this   distance  the  velocity  of   the  round   ball  was 

rapidly  diminished j  while  the  conical  hall  shot  from 
the  rifle  continued  its  momentum  undiminished. 

Another  missile,  which   has  been   more  extensively 


CAMP    DUTIES    OF    A    REGIMENTAL    SURGEON.        121 

used  in  the  present  war  than  in  any  preceding,  is  the 
rifled  shell,  as  fired  from  artillery.  In  both  contend- 
ing armies  rifled  artillery  appears  to  he  a  weapon 
upon  which  much  reliance  is  placed,  and  which  is 
brought  into  continual  use — artillery  duels  not  onty 
preceding  each  battle,  but  being  a  constant  element 
in  the  fight.  Whether  used  at  a  distance  of  fivo 
miles,  as  in  the  Siege  of  Charleston,  or  at  short  range, 
the  explosion  of  shells  among  troops  makes  frightful 
wounds.  The  mutilation  of  the  slain  upon  every 
hat  tie-field  attests  the  terrible  efficacy  of  the  rifle 
shell  and  modern  artillery  missiles. 

Let  us  now  define  the  duties  of  a  surgeon  in  the 
.Confederate    service    in    the    regimental    hospital,    in 
camp,  and  on  the  battle-field. 

•  Camp  Duties  of  a  Regimental  Surgeon. — We  have 
already  shown  that  the  fire  of  an  enemy  never  deci- 
mates an  opposing  arm}'.  Disease  is  the  fell  destroyer 
Of  armies,  and  stalks  at  all  times  through  encamp- 
ments. Where  balls  have  destroyed  hundreds,  insid- 
ious diseases,  with  their  long  train  of  symptoms, 
and  quiet,  noiseless  pi*ogress,  sweep  away  thousands. 
To  keep  an  army  in  health  is,  then,  even  more  im- 
portant than  to  cure  wounds  from  the  battle-fields. 
But,  as  surgeons  in  the  service  arc  expected  to  bo 
skilled  in  both  departments,  so  that,  in  either  case, 
the  troops  under  their  care  might  suffer  no  detriment, 
tiny  should  be  thoroughly  prepared  for  the  very  re- 
sponsible positions  which  they  fill.  Conservative  sur- 
gery requires  much  more  at  the  hands  of  the  surgeon 
than  the  destructive  practice  of  former  times.  Every 
Burgeon  should  now  prepare  himself  for  the  field,  by 
familiarizing  himself  with  operative  Burgery.  Half- 
knowledge  leads  to  meddlesome  surgery,  which  is  far 


122       CAMP    DUTIE8   OF   A    REGIMENTAL   BUROEON. 

worse  than  no  surgical  assistance.  Many  a  wounded 
soldier  has  felt  heavily  the  busy  hand  of  the  willing  sur- 
n  who  lacked  the  guiding  h  id.  The  Burgeon  in  the 
nfederate  service  has  charge  of  a  number  of  very 
valuable  lives,  as  the  very  best  men  in  the  country  arc 
in  the  army,  and  the  necessity  imposed — by  the  al>- 
sence  of  consulting  aid — of  deciding  tin-  most  serious 
and  critical  cases  upon  his  own  unaided  judgment 
demands,  upon  his  part,  self-reliance,  which  can  only 
be  based  upon  previous  preparation.  Cam])  life  gives 
a  surgeon  much  food  for  thought  and  ample  personal 
experience,  but  gives  him  no  time  to  consult  authors 
and  improve  himself  with  books.  lie  does  not  sei 
ureal  a  variety  of  diseases  as  are  met  with  in  civil 
practice,  hut  he  lias  a  wider  field  for  observing  the 
influences  of  external  modifying  circumstances  —  as 
exposure,  improper  food,  imperfect  clothing,  irregular 
work,  want  of  cleanliness,  and  depressing  or  exhila- 
rating mental  influences  upon  young,  healthy  men. 
The  diseases  of  a  soldier,  like  those  of  most  trades, 
are  peculiar — each  trade  begetting  its  own,  while  it 
M-ives  immunity  to  others.  The  greater  uniformity  in 
age,  constitution,  modes  of  living,  exposure  to  similar 
external  influences,  and  strict  discipline,  modify,  to  a 

considerable  extent,  the  diseases  of  camp.  It  is  espe- 
cially the  crowding  together,  with  the  animal  emana- 
tions from  BUch  a  number  of  living  beings,  that  gives 
Character  to  the  phases  of  camp  disease. 

The  preservation  "f  the  health  <>/  ike  soldier  being  the 
sole  '(uii/  of  the  military  surgeon,  he  will  lie  expected  to 
use  rvrvy  means  within  his  reach  to  attain  this  de- 
Birable  end,  and  more  especially  by  a  rigid  observance 
of  those  forms  of  discipline  and  economy  which  are 
under  the  direction  and  surveillance  of  the  military 
officers.     As  diseases  will  arise  among  troops,  and  as 


CAMP   DUTIEB   OF   A   REGIMENTAL   .SURGEON.       123 

very  few  of  these  can  not  be  arrested  by  means  of  art 
when  skilfully  applied  at  an  early  period,  care  should 

be  taken  that  medical  skill  be  promptly  resorted  to  at 
the  very  first  Bign  of  indisposition.  Hygiene  must 
first  claim  his  attention,  under  the  adage,  "Preven- 
tion is  better  than  euro."  If  the  troops  are  about 
forming  an  encampment,  he  must  examine  the  ground, 
and  see  whether  any  causes  exist  for  rendering  the 
place  insalubrious.  When  in  a  friendly  country,  ho 
should  seek  information  from  the  local  physicians, 
which  will  not  only  give  him  a  better  insight  into  the 
sanitary  condition  of  the  point  selected,  but  will  also 
instruct  him  upon  the  diseases  prevalent  in  the  local- 
ity, and  the  means  which  local  experience  and  obser- 
vation have  proved  most  effective  in  controlling  such 
diseases,  lie  must  see  that,  when  practicable,  the 
troops  in  camp  are  supplied  with  dry  straw  for  beds, 
and  that  they  air  the  same  daily,  along  with  their 
tents,  so  as  to  ensure  a  healthy  place  for  repose. 
With  the  officers  of  the  regiment,  he  must  ace  to  it 
that  the  soldiers  are  properly  clothed,  and  well  fed 
with  wholesome,  nutritious  food,  and  supplied  with 
an  abundance  of  good  water,  and,  from  time  to  time, 
should  suggest  to  the  commanding  officer  such 
changes  in  the  diet  as  will  be  conducive  to  the  health 
Of  the  command.  If  the  water  is  bad,  ho  should 
study  how  it  can  be  improved,  so  as  not  to  act  inju- 
riously upon  the  men.  Cleanliness  of  the  encamp- 
ment, of  the  tent,  and  also  of  the  body  and  clothing 
0f  soldiers,  should  never  be  forgotten.  He  should 
point  out  to  the  commanding  officer  all  nuisances 
which  promise  to  be  detrimental  to  the  health  of  the 
corps,  and  urge  their  removal— suggesting  how  they 

Can  beet   be  deposed  of      Much  of  the  sickness   in  the 


1  .' I       CAMP    DUTIES    OF    A    REGIMENTAL    BURG! 

army  can  !"•  attributed  to  a  dereliction  of  this  duty 
upon  the  pari  of  the  medical  officer. 

The  hospital  tents,  with  the  approbation  <>i"  the 
commanding  officer,  will  be  pitched  upon  a  dry,  well- 
drained  Bpot,  if  a  bailding  can  not  be  obtairfed  tor 
hospital  use,  and  it  is  the  duty  of  the  regimental  Bur- 
geon t"  attend  to  the  proper  furnishing  of  the  same 
with  all  possible  conveniences  for  the  sick.  1 1  »•  will 
enforce  all  proper  hospital  regulations  to  promote 
health  and  prevent  contagion,  by  ventilation,  scru- 
pulous cleanliness,  frequent  changes  oi  bedding,  linen, 
etc. 

At  the  Burgeon's  morning  call  the  sick  of  the  regi- 
ment will  bo  conducted  to  the  hospital  by  the  lirst 
sergeants  of  1 1 1  *  *  various  companies,  who  will  each 
hand  t<>  the  Burgeon  a  list  of  all  the  Bick  of  the  com-! 
pany,  on  which  the  Burgeon  will  state  who  are  to 
remain  or  go  into  hospital,  :ui<l  who  are  to  return  to 
quarters  as  Bick  or  convalescent}  what  duties  the 
convalescents,  in  quarters,  are  capable  of  performing j 
what  cases  arc  feigned,  and  any  other  information  in 
regard  to  the  si<-k  of  the  company  be  may  have  to 
communicate  to  the  oompany  commander.  Il<'  will 
then  distribute  the  patients  in  the  hospital;  sec  that, 
they  are  properly  provided  with  comfortable  bods; 
enter,  in  the  proper  register,  the  name,  rank,  com* 
pany,  and  disease,  and  in  the  <lh't  and  prescription 

1 k   the  medicines  which  the  case  requires,     [f  his 

assistant  is  not  present,  and  his  steward  is  not  com- 
petent, he  propares  the  medicines  and  superintends 
their  administration.  He  will  visit  the  hospital  each 
day,  as  frequently  a*  the  Btate  of  the  Bick  may  re- 
quire. Should  any  Boldier  be  taken  suddenly  sick, 
his  case  is  at  once  reported  to  the  surgeon,  who  will 


('AMP    DUTIES    OF   A   REGIMENTAL   SURGEON.       125 

visit  and  prescribe  for  him  in  his  tent,  unless  the  case 
threatens  to  be  serious,  when  he  should  be  removed 
without,  delay  to  the  hospital. 

Convalescents,  on  coming  out  of  the  hospital,  are 
not  to  be  put  on  duty  till  the  surgeon  certifies  to  the 
commanding  officer  that  they  have  perfectly  recover- 
ed;  for  which  purpose  it  is  the  duty  of  the  surgeon  to 
make,  daily,  at  morning  parade,  a  particular  inspec- 
tion of  these  men,  so  as  to  prevent  any  remaining 
longer  exempt  from  duty  than  the  state  of  their 
health  renders  absolutely  necessary.  After  the  sur- 
geon's call,  lie  will  make  a  morning  report  of  all  the 
sick  and  disabled  to  the  commanding  officer.  He  also 
recommends  that  leave  of  absence  be  granted,  on  fur- 
lough, to  those  convalescents  who  will  recover  more 
rapidly  by  change  of  air,  scene,  and  life;  or  discharges 
for  those  whom  experience  has  proved  physically 
unfit  for  the  arduous  duties  of  camp  life.  When  it  is 
his  opinion  that  a  case  can  not  be  as  conveniently 
treated  in  camp  as  in  a  general  hospital,  he  recom- 
mends a  transfer  to  the  commanding  officer,  and  for- 
wards with  the  patient  a  descriptive  list,  a  history  of 
the  case,  and  the  course  of  treatment  which  has  been 
pursued. 

When  soldiers  are  discharged,  as  cured,  from  the 
hospital,  or  die,  or  are  fhrloughed  or  discharged  from 
service,  if  is  the  duty  <>f  the  surgeon  to  notify,  imme- 
diately, the  captain  of  the  company  to  which  the  sol- 
dier belongs,  so  that  the  proper  steps  may  be  taken 
which  the  necessities  of  the  case  may  require. 

The  regimental  surgeon  is  the  recognized  head  of 
the  regimental  hospital  and  is  responsible  for  the 
organization  and  proper  keeping  of  the  same.  He 
will,  therefore,  prepare  and  enforce  all  of  those  rules 
so  necessary  in  a  well-regulated  hospital,  for  estab- 


120       CAMP   M  A    REGIMEN  PAL    f 

lishing  order  and  keeping  np  a  military  organiza- 
tion. When  soldiers  enter  snch  q  hospital,  all  control 
iv« >m  without  is  suspended,  and  line  or  staff  officers 
are  do!  allows!  to  interfore  in  any  way  with  the 
managomenl  of  the  oaae.  The  surgeon  distributes  the 
patient-,  according  to  convenience  and  the  nature  of 
their  complaints,  into  hospital  tents,  or  leaves  them 
in  their  own  quarters,  and  visits  them  each  day  as 
often  as  the  state  of  the  sick  may  require,  Accompa- 
nied by  the  steward  and  nurse.  He  keeps  the  proper 
register  of  the  hospital,  and  directs  the  prescription 
and  di.t  of  the  sick;  superintends  the  preparation  of 
the  reports,  records, pay-rolls, and  descriptive  lists;  and 
also  keep-  a  constant  supervision  over  the  dispensary, 
instruments,  medicines,  and  hospital  Btores,  as  also 

over  the  hospital  expenditures,  and  the  preparation  of 

the  requisitions  and  returns.  He  keeps  an  order  and 
letter  book,  in  winch  is  preserved  copies  of  all  requisi- 
tions and   invoices,  as   well   as   all   orders   and    letters 

relating  to  his  duties.  He  makes  a  monthly  report  to 
the  medical  director,  and  a  quarterly  report  to  the 
Burgeon-general,  of  the  sick  and  wounded  and  of 
deaths,  and  also  of  certificates  for  discharges  from  dis- 
ability— all  of  which  are  forwarded  through  the  brigade, 
division,  and  corps  surgeon  to  the  medical  dire 
lie  will  also  prepare  the  muster  and  pay  rolls  of  the 
hospital  Steward.      Should  a  soldier  die  in  the  hospital, 

i be  surgeon  takes  charge  of  his  offsets  and  reports  the 
sane,  turning  over  all  money  and  other  articles  except 
clothing  to  the  quartermaster  of  the  regiment,  taking 
therefor  receipts  in  duplicate,  one  of  which  he  for- 
wards to  the  commander  of  the  company  of  which  the 
soldier  was  a  member,  to  he  s,.nt  by  him  to  the  family 
of  the  deceased,  and  the  other  to  the  Second  Auditor 
of  the  Treasury,     lie  will  enforce  the  proper  hospital 


CAMP    DUTIES   OF   A   REGIMENTAL   SURGEON.       127 

regulations  to  promote  health  and  prevent  contagion, 
by  examining  daily  into  the  hygienic  condition  of  the 
hospital  as  regards  cleanliness,  ventilation,  over-crowd- 
ing, proper  food,  etc.  He  will  require  the  steward  to 
take  due  care  of  the  stores  and  supplies,  to  keep  a 
regular  account  of  all  issues,  to  prepare  the  provision 
returns,  and  to  receive  and  distribute  the  rations. 

As  the  sick  in  all  hospitals  are  not  able  to  consume 
the  ample  supply  of  food  which  the  government  re- 
cognizes  as  a  ration,  and  which  is  issued  to  all  sol- 
diers, whether  well  or  side,  the  surgeon  should  direct 
the  steward  to  draw  from  the  commissary  only  BUCh 
quantities  as  are  required  for  the  hospital,  and  to 
commute  in  money  for  the  stores  not  drawn.  This 
surplus  forms  a  hospital  fund,  an  account  of  which 
the  surgeon  keeps,  and  which  can  be  expended  for 
comforts  for  the  sick,  both  as  regards  subsistence  or 
hospital  furniture.  The  condition  of  this  fund  is 
transmitted,  monthly,  to  the  surgeon-general. 

AIL  requisitions  upon  medical  purveyors  for  hospi- 
tal and  medical  stores  must  come  from  the  senior  sur- 
ge in,  with  the  approval  of  the  commanding  officer, 
certifying  that  the  same  are  necessary  for  the  sick, 
and  that  the  requisition  conforms  strictly  to  the  Blip* 
ply-table  for  field  service.  These  requisitions  are 
drawn  out  by  the  surgeon  in  the  proper  form  (No.  5 
of  Medical  Regulations),  always  in  duplicate,  stating 
what  medicines  arc  on  hand,  and  for  how  many 
required,  and  arc  sent  to  the  modical  director,  or, 
should  there  he  no  one  acting  in  his  district,  to  tllS 
surgeon-general,  for  approval,  All  Btores  received 
from  the  medical  purveyor  must  be  receipted  for  in 
duplicate  to  the  ijurgeon-goneral,  by  the  senior  aur 
gcon,  who  also  notifies  the  medical  purveyor  ol  their 
reception. 


L2S 


MKHK  Al.    OUTFIT    Y'M    A    REGIMENT. 


The  following  comprises  tho  medical  outfit   for  a 
regiment  medicine-chest  : 


AllTIOI.KS. 


NTITY.       VW 


Aluminia 

Caoaphorte- ... 

Cerati  Bimplioia 

Raainsa 

Bmplastrum  Cantbaridia 

Alcobnlia 

<  lopaibaQ 

Oloum  Olirae 

••      Rioini 

"      Terebiuthinir 


lb. 


bot 


B  * 


Aoacia,  pulv 

Capaioum,  pulv.    . . . 

Magnesia  Sulpbatia. 

bb  Bitartratia  . 

Palveria  Cinoh«mae<  . 

"        Lini 

"         Khci 

Quiniffi  Sulpbatia. . . 

Binapia  N  igrae 

Bodes  Bioarbonati8. . 
Bolphurua  Loti 


Aoidi  Tartarici 

Bydrargyri  Chlor.  Mitis  . 

Plumbi  Acetal  ia 

Potaasii  [udidi 

Pulveria  '  Ipii 

Sodte  i  i  Potuaa.  Tartralia. 

Cbloroforini 

Liquoria  Ammonias 

Bpiritua  AStheris  Comp. . . 

"  "        Nitrioi. . 

Syi  n|i  SoillaD 

linot.  Opii 

••     Campb 

Vini  Colobipi  Sominia. . . . 

Hydrargyri  Cum  Creta. . . 

Pulveria  Aloea 

I  pecac.  el  * » | .  i  i  . . 
Zinc!  Sulpbal i- 


8  os. 


S   OZ. 


2  oc. 
2  " 
2  " 
2    " 


Argenti  oitratia,  fused 

Antin ii  el  Putoss.  Tartratia 

Perri  el  Quiuiaa  Citratie 

[odinii 

lAorpbiaa  Sulpbatia 

Dnguenti   Hydrargyri. 


.M:.v-;i-  pil.  Hydrarg; 


Nit  rat  ia. 


Hi. 


C    f    B* 

£  ??  E. 


01  »    D" 

2  8    B 

Z  5' 
5' 
3  ^2. 


—  £  " 


?r  a.  „: 


W    r»    S> 


DUTIES  OF  ASSISTANT  REGIMENTAL  SURGEON. 


129 


Ahtici.es. 


■Quantity.     VESSELS 


Bandages,  roller,  assorted  . 

Eniplnstruui,  adhesivi 

"  Iohthyocollse 

Measures,  graduated 

Mortar  and  Pestle 

Oleum  Tiglii 

Pencils,  hair 

PilulsB  Cathartic  Com  p. . . . 

"       Opii 

Scales  anil  weights 

Spatulas 

Sponge 

Tiles 


A  store-chest,  with  the  following  contents,  accom- 
panies the  medicine-chest: 


Instruments.  Amputating,  Bets. .No. 

Ball  Forceps " 

Bougies,  gum  elastic " 

Catheters '• 

'■  silver " 

Cuiqung-tJlasses...-. " 

Pocket  Sets " 

Lancets,  spring " 

"         thumb     " 

Trobnngs " 

ScariBcators  " 

Splints  assorted  'set  ofl4) " 

Syringes,  enema •' 

penis " 

Troth,  extracting,  sets " 

Toorniqncts,  field " 

spiral " 

l'i  macs.  Hernia " 

Arrow- Root lbs, 

Candles " 

•  Nutmegs  ol 

Tea His 

Whiskey,  quart  bottles doz 

Bandages   roller '• 

Bandages,  suspensory nos 

Binders'  Hoards •' 

•  'oiks  doi 

Cork-Screws ■ 


Cotton  Batting 

"       Wadding 

Flannel,  red 

Hatchets 

Bones  

Ink.  2  OK.  bottles 

Lint 

Muslin 

Needles 

Paper  envelopes 

|      '■      wrapping  

"      writing 

Pencils,  hair  

"         lead 

(Pens,  steel  

Pins,  assorted 

Bason 

Rasor-8trop 

-  

silk,  surgeons' 

Sponge 

Tape  

Thread,  linen 

Towels 

Twine 

Wafera,  '-.,.  "/.  boxes  , 
Wax.  Sealing 


•yds. 


..lbs. 
.yds. 
.nos. 


.quires. 
Nob, 


doz, 

.papers. 


....lbs. 


.dos. 

.-lbs. 


Duties  oi  Assistant  Regimental  Surgeon. — The 
duties   of  the   assistant  regimental    surgeon    are,  in 


130      DUTIES  Of  ASSISTANT  REGIMENTAL  BURGEON. 

many  respects,  similar  to  those  of  the  Burgeon.  If 
be  lias  the  confidence  of  his  superior,  the  patients  arc 
equally  divided  between  them;  he  treating  a  certain 
number  of  >i<k.  ordinarily  without  interference  from 
the  Bonior  Burgeon,  except  they  be  serious  cases, 
when  he  seeks  advice  from  the  regimental  Burgeon. 
Although  this  is  the  common  course  pursued,  it  is  not 
bo  from  right,  but  by  sufferance  of  the  senior  Bur- 
geon. In  the  army  regulations,  the  senior  surgeon 
being  the  superior  officer,  the  assistant  surgeon  is 
under  his  control.  Besides  attending  to  a  number  p# 
patients,  he  is  expected  to  make  up  medicines,  and 
Bee  that  the  patients  get  them  at  the  proper  time, 
apply  dressings,  bandage  fractured  limbs,  keep  the 
register,  diet,  and  prescription  hooks,  and  assist  in 
compiling  the  monthly  and  quarterly  returns.  When 
a  detachment  is  sent  off  upon  special  service,  the 
assistant  surgeon  accompanies  it  as  medical  officer. 

When  epidemics  occur  in  camp,  then  the  duties  of 
the  medical  officers  become  very  arduous;  the  daily 
and  nightly  toil  which  they  are  compelled  to  undergo, 
the  fatigue  of  body  and  anxiety  of  mind  which  is 
their  daily  routine,  soon  breaks  them  down,  and 
many  an  over-zealous  surgeon  becomes  a  prey  to  the 
diseases  which  his  constant  efforts  are  trying  to  sub- 
due in  others.  This  is  particularly  the  case  when 
typhus  is  raging  in  camp;  when  a  neglect  of  those 
hygienic  precautions  which  the  medical  officers  are 
instilling  into  the  men  causes  many  a  victim  in  the* 
medical  ranks.  Under  such  conditions,  it  becomes  as 
imperatively  the  duty  of  the  surgeons  to  take  care 
of  themselves  as  to  attend  to  the  sick;  for,  should 
they  needlessly  sacrifice  their  lives,  they  may  entail 
severe  suffering  on  their  regiments.  The  Crimean 
surgeons   were   severely   censured,  after   spending  all 


PURSUIT    OF    MEDICAL    STUDIES.  131 


day  in  tlie  typhus  and  cholera  hospitals,  with  their 
tainted  atmospheres,  for  remaining  there  during  the 
night  also,  when  there  was  no  necessity  tor  it.  It 
was  a  useless  ami  dangerous  imprudence,  an  exagge- 
ration of  duty,  which  deprives  the  army  of  well- 
informed  men,  and  impairs  the  utility  of  tho  service. 

In  the  Crimea,  the  surgeons  would  frequently  meet 
together  for  scientific  conference  and  for  mutual  in- 
struction.  Here  each  gave  his  experience,  and  com- 
pared the  results  of  different  methods  of  treatment. 
Their  meetings  always  terminated  in  practising  am- 
putations, resections,  and  the  ligation  of  arteries  on  the 
dead  subject.  The  object  of  this  was  not  only  to  gain 
dexterity  in  the  operative  manual,  but  also  to  find  out 
who  were  the  most  skilled,  and  therefore  most  worthy 
of  being  entrusted  with  important  duties.  It  is  said 
that  the  mortalit}'  of  the  army  amounted  to  two  hun- 
dred per  day,  which  gave  ample  material  for  such 
practice.  These  meetings  were  presided  over  by  one 
of  the  most  distinguished  staif  surgeons  or  medical  di- 
rectors, who  would  often  deliver  to  the  society  prac- 
tical lectures  upon  the  treatment  of  gunshot  wounds. 
This  plan  might  be  carried  out  in  all  armies,  as  it 
must  redound  to  the  benefit  of  both  surgeons  and 
patients. 

In  some  of  our  armies  this  excellent  [dan  has  been 
adopted — societies  in  the  field  having  been  formed  for 
interchanging  views  and  advancing  the  general  science 
of  military  surgery,  in  Richmond,  the  child'  head- 
quarters of  the  army,  an  association  of  army  and  navy 
Burgeons  has  been  formed,  presided  over  by  the  sur- 
geon-general, which  has  collected  within  its  limits  the 
medical  and  surgical  talent  of  the  Confederacy.  Ai 
its  meetings  the  important  and  mooted  subjects  of  mili- 
tary surgery  are  freely  and  thoroughly  discussed,  and 


132    DUTIES  OF  THE  BURGEON  ON  THE  BATTLE-FIELD. 

much  valuable  information  elicited.  In  order  to  reach 
the  individual  experience  of  army  surgeons,  questions 
of  special  interest  arc  proposed,  and  disseminated  by 
means  of  a  circular,  by  tbc  presiding  officer,  to  tbe 
medical  officers  of  the  army  throughout  the  entire 
Confederacy,  and  ample  time  is  given  to  obtain  indi- 
vidual opinions,  based  upon  experience,  which  are 
brought  forward  when  these  questions  are  discussed 
before  the  association.  By  adopting  this  plan  the  very 
best  results  are  obtained,  and  the  experience  of  the 
medical  staff  collected. 

Duties  of  the  Surgeon  on   the   Battle-field. — 
The  common  fear  which  depresses  the  soldier  on  the 

eve  of  a  battle,  more  than  any  other,  is  not  so  much 
death,  but  tbe  dread  of  mutilation.  Bullets  are  neither 
respecters  of  parts  nor  persons;  and  tbe  prospect  of 
lining  an  eye,  an  arm,  or  leg,  makes  many  a  brave  man 
quail  before  the  ordeal  through  which  he  is  to  pass. 
So  that,  before  a  battle,  there  is  a  vague,  uneasy  rest- 
lessness— a  foreboding  of  coming  evil  —  which  takes 
possession  of  tbe  bravest,  and  can  not  lie  driven  off  ex- 
cept by  the  commencement  of  the  tight.  The  early 
booming  of  cannon  braces  all  for  action  ;  all  thoughts 
of  fear  or  self  are  now  discarded,  tbe  demon  of  war 
rules  triumphantly  over  the  assembled  host,  and  sup- 
presses, through  thirst  for  blood  and  desire  for  victory^ 
all  depressing  influences.  There  is  something  in  the 
smell  of  gunpowder  which  makes  men  forget  their 
originj  by  its  magic  spell  women  are  made  brave,  and 
cowards  heroes.  In  tbe  eagerness  of  the  fray  an  in- 
toxication guides  all  to  acts  of  daring.  Who,  in  his 
sober  moments,  would  walk'  up  to  the  mouth  of  a 
loaded  cannon  to  which  a  torch  is  being  applied  ?  Yet, 
on   the  battle-field  find  the  man  who,  at  the  word  of 


MEDICAL  SUPPLIES  REQUIRED  ON  THE  FIELD.        133 

Command,  and  while  under  the  stimulating  intoxica- 
tion from  gunpowder,  would  not  face  certain  destruc- 
tion !  Fortunate  it  is  that  nature  has  so  constituted  us, 
or  the  terror  of  pursuing  a  course  which  duty  dictates 
would  be  agonizing  indeed.  The  surgeon  on  the  battle- 
field must  participate  in  the  dangers,  without  the 
stimulation  of  the  conflict ;  he  requires,  therefore,  a 
double  proportion  of  courage  to  sustain  him  in  the  try- 
ing part  which  he  has  to  perform. 

Upon  the  eve  of  a  battle,  the  regimental  surgeon 
has  much  to  do  to  prepare  facilities  for  the  treatment 
of  the  wounded,  lie  must  see  that  the  hospital  stores 
are  brought  up  with  the  ammunition  wagons — as  the 
articles  for  treating  the  wounded  and  saving  the  life 
of  comrades  arc  fully  as  important  as  those  for  the  de- 
struction of  the  enemy.  lie  examines  his  stores,  and 
satisfies  himself  that  nothing  which  will  be  required 
for  the  wounded  has  been  omitted  or  forgotten.  Re 
examines  his  instruments,  his  supply  of  bandages, 
lint,*  india-rubber  cloth,  oiled  silk,  or  waxed  cloth,  etc.; 

*Carded  cotton  has  been  extensively  used  in  military  surgery,  and 
was  found  in  the  Crimea  to  be  a  good  substitute  for  lint  by  the  French 
surgeons,  with  whom  an  abundance  of  lint  is  a  nine  qi«i  Hon  in  the 
treatment  of  wounds.  As  it  can  be  so  easily  obtained  in  any  part  of 
the  Confederate  States,  and  at  so  trifling  a  cost,  it  promises  speedily  to 
usurp  the  place  of  the  officinal  preparation.  Now  that  tents  and  meshes 
are  scarcely  used,  and  receptacles  for  collecting  pus  are  denounced  in 
modern  surgical  practice,  wc  see  no  reason  why  carded  cotton,  with  its 
very  soft,  elastic  fibre,  would  not  make  a  more  soothing  dressing  than 
lint,  which  is  often  formed  of  coarse,  hard  threads,  which  would  leave 
their  marks  upon  a  sensitive,  inflamed  surface,  and,  therefore,  must  be 
the  uurccognized  cause  of  pain. 

Mayor,    in   his   work,    "  /Jandages  el    Apparcil  d  Patuement,"   after 
mentioning  that  the  use  of  raw  cotton   had  been   proscribed    without 
cause  in  the  treatment  of  wounds,  reiterates  what  would   be  evident  to 
every  serious  investigator,  that  far  from  being  hurtful,  this  su1> 
so  light,  5'-  »oft,  -"  clean,  w  dimple,  f  abundant,  and  bo  easily  obtained, 


l.'il        MEDICAL  SUPPLIES  REQUIRED  OH  Till.  FIELD. 

Ibc  rule  adopted  in  European  armies  being,  t<>  have 
roady  dressings  for  one-fiflli  <>f  the  command  going 
into  action.  He  sees  thai  chloroform  and  opium,  or 
morphine,  the  chief  source  of  comforl  to  the  wounded, 
arc  at  hand  in  sufficient  quantity.  Water  he  has  not 
overlooked,  as  an  abundant  supply  will  be  needed  to 
meet  tbe  incessant .  unmitigated  thirst  of  the  wounded. 
!I«'  should  be  well  supplied  with  astringents,  of 'which 
the  perchloride  or  persulphate  «»i'  iron  is  the  best  Id 
control  annoying  hemorrhage.  So  should  also  havea 
moderate  supply  of  brandy  to  revive  those  exhausted 
from  hemorrhage,  oil  to  grease  their  wounds,  and  a 

U  the  very  best  n r t i < •  1  < ■  thai  con  be  used.  All  will  acknowledge  that,  fur 
protecting  parts  from  pressure,  aud  for  equalizing  tbe  pressure  of  tbe 
apparatus,  this  is  t lie  preferable  article  for  many  reasons.  For  the 
dressing  of  wound.*  lint  is  used,  because  ii  i.-  thought  soft  and  soothing 
to  the  raw  surface — how  much  better,  on  this  very  account,  is  cotton 
than  the  finest  lint?  If  cotton  is  used,  and  its  claims  recognized  as  an 
application  to  the  raw,  inflamed,  sensitive  surface  of  a  burp,  with  how 
much  more  reason  could  it  he  applied  to  tbe  comparatively  healthy  sur- 
face of  a  wound?  Tbe  best  lint  is  obtained  by  scratching  clotb  until  it 
yields  a  soft  down,  which,  when  obtained,  i-  nothing  but  raw  cotton, 
\i/  :  reducing  the  cloth  to  its  primitive  element.  Hereafter  there  will 
nol  be  that  ilc  in  a  ml  foi  liul  as  hi  rotofoi  c  ;  and,  in  times  of  war,  the  fe- 
male population  of  e  < ntry  will  not  bo  called  upon   to  use  nil  of  tln-ir 

exertions  in  Bcraping  lint  from  rags,  many  of  which  already  contain  the 
germs  of  disease,  when  any  number  of  hale-  of  cotton  lint  can  be  ob- 
tained  at  once,  and  at  little  expense,  and  without  trouble.  Female 
labor  has  been  much  more  profitably  employed,  during  our  struggle 
fur  Independence.  Lint  has  been  but  little  used,  as  the  cold  water  appli- 
cation to  wounds  is  the  universal  treatment  in  the  army,  which  excludes 
the  ii.-e  of  lint,  Many  leading  army  surgeons  haie  discarded  lint  alto- 
gether as  an  encumbrance  t'>  Burgioal  dressings, 

Much  can  also  be  said  of  new  cloth  verniu  the  old  linen  of  titno- 
honored  reputation.  Suffice  it  to  say,  in  this  connection,  that  an  army 
should  never  clog  Its  movements  by  an  exci  of  baggage,  and  that  the 
old  linen  (which  can  be  used  but  once)  required  for  an  army  is  no 
small  item.  New  cloth  can  be  washed  a  dozen  times,  if  required,  which 
in  itself  is  no  mean  recommendation. 


PANNIERS    FOR    FIELD    SERyiOE.  L35 

little  tea,  sugar,  and  such  medical  comforts  as  will  re- 
fresh and  .support  the  wounded. 

Having  selected  from  the  general  stock  those 
articles  which  he  will  need,  such  as  all  articles  for 
dressing,  viz:  cotton,  lint,  cloth,  bandages,  oiled  silk, 
sponges,  ligatures,  adhesive  plaster,  splints  for  treating 
all  varieties  of  fractures,  amputating  and  dressing  in- 
struments, with  medicines  and  stimuli,  and  a  lull  sup- 
ply of  good  water— they  are  carefully  put  upon  a 
pack-mule  in  two  strong,  iron-bound  hexes,  called  pan- 
niers, one  hanging  on  either  side  of  the  saddle.  One 
is  usually  devoted  to  medicines — the  other  is  used  for 
dressing  apparatus.  This  distribution  gives  the  sur- 
geon great  facility  in  moving  about  the  field  to  those 
positions  where  his  services  may  be  most  required, 
while  it  dispenses  with  the  hospital  store  wagon, 
which  is  altogether  too  cumbersome  to  follow  light 
troops  in  their  varied  and  active  movements.  In 
European  armies  every  regiment  has  such  a  pannier, 
which  is  continually  resupplied  from  the  medical  store 
wagons.  The  commanding  general  may  sometimes 
have  good  reasons,  under  particular  circumstances, 
for  ordering  the  medical  wagons  to  remain  behind 
with  the  baggage;  then  some  other  conveyance  for 
all  needful  medical  supplies  for  the  wounded  becomes 
imperative. 

Panniers  are  used  only  to  a  limited  extent  in  our 
armies,  from  the  scarcity  of  supply.  We  are,  there- 
fore forced  to  use  ambulance  wagons  instead  of  pack- 
horses  in  our  rapid  movements. 

As  panniers  are  sometimes  objected  to  on  account 
of  their  si/.e.  and  as  modern  surgery  recognizes  but 
few   medicines  as   really   necessary   on    the    field,   light 

leather  water  proof  cases,  which  are  carried  by  an  or- 
derly, are  found   preferable      A  great  convenien 


136  HOSPITAL    KNAPSACK. 

the  surgeon  is  the  modern  addition  < »1"  a  hospital 
knapsack  t<>  bis  equipments,  which  enables  his  orderly 
to  carry  conveniently,  for  immediate  use,  such  articles 
as  the  attendance  upon  the  sick  and  wounded  require. 

The  hospital  knapsack  which  has  been  issued  to  tin* 
Confederate  army  is  framed  similarly  to  the  ordinary 
knapsack,  but  larger,  being  sixteen  inches  long,  four- 
teen inches  wide, and  six  inches  deep.  The  interior  is 
divided  by  wooden  partitions  into  four  compartments, 
with  a  broad  band  of  leather  tacked  across  the  lower 
portion  of  the  enclosure  to  prevent  the  contents  from 
dropping  out.  A  leather  apron,  similar  to  that  of  an 
ordinary  knapsack,  covers  the  front  of  the  knapsack. 
The  frame  is  surmounted  by  a  horseman's  valise, 
which  is  convenient  for  carrying  large  bottles,  dress- 
ings, and  instrument-. 

The  hospital  knapsack  contains  the  following  drugs, 
viz:  tannic  acid,  1  oz.;  nitrate  of  silver,  fused,  \  oz.; 
simple  cerate,  ]  Hi.;  chloroform,  J  lb.;  adhesive  plaster, 
2  yards;  isinglass  plaster,  2  yards;  powdered  alum,  2 
oz.j  aromatic  spirits  of  ammonia,  2  oz.j  Hoffman's  ano- 
dyne, 2  oz.j  brandy,  1  bottle;  muriate  tincture  of  iron, 
4  oz.;  laudanum,  \  oz  ;  paregoric, 4  oz.;  comp.  cathartic 
pills,  t  do/..;  camphor  and  opium  pills  (camphor  2 
grains,  opium  1  grain  each),  1  doz.;  opium  pills  (1 
grain  each),  2  doz.;  acetate  of  lead  and  opium  pills  (lead 
2 grains, opium  1  grain  each),  2  doz.;  and  quinine  pills 
(.'{  grains  oach),  4  doz.  And  in  a  haversack,  made  of 
wator-proof  enamel  led  cloth,  is  carried  bandages,  6  rolls; 
Sperm  candle,  1  ;  lint,  I  ft).;  medicine  cup,  1  ;  pins,  1 
paper;  and  2  pieces  of  Bponge.  Assistant  surgeons 
should  carry  a  small  leather  haversack,  with  a  flap 
cover,  to  button  for  security.  This  will  contain  his 
pockot  instruments,  torsion  forceps,  light  dressings, 
pins,  sponges,  ot< 


HOSPITAL    KNAPSACK;  137 

In  making  the  daily  rounds  of  the  sick  in  camp, 
when  they  arc  scattered  in  their  tents  and  not  con- 
centrated within  a  hospital  enclosure,  this  knapsack, 
with  contents,  carried  by  an  orderly  or  the  hospital 
steward  of  the  regiment,  will  save  much  delay  and 
trouble  in  the  dispensing  of  drugs.  "When  carried  on 
the  battle-field  many  articles  may  be  dispensed  with, 
and  in  their  stead  the  knapsack  should  contain  lint, 
bandages,  adhesive  plaster,  sponges,  and  a  bottle  of 
sweet  oil,  with  pins  and  tape,  for  the  dressing  of 
wounds;  a  bottle  of  the  perchloride  of  iron,  for  control- 
ling hemorrhage;  field  tourniquets;  a  bottle  of  mor- 
phine, for  allaying  pain ;  chloroform,  should  an  urgent 
case  demand  an  immediate  operation  to  save  life,  and 
a  quart  or  more  of  brandy  ;  also  candles  and  matches, 
which  arc  indispensable,  as  no  efficient  aid  can  be  giv- 
en to  the  wounded  upon  the  field  after  darkness  sets 
in,  without  them.  The  orderly  who  carries  the  knap- 
sack also  carries,  suspended  to  his  person,  a  large 
canteen,  three  times  the  ordinary  size,  filled  with 
water,  and  also  a  tin  cup.  The  knapsack  should  be  so 
arranged  that  all  the  contents  will  be  exposed  to  view 
without  unpacking. 

If  the  army  would  adopt  those  regulations  of  the 
Prussian  service  which  compel  every  soldier  going 
into  battle  to  carry  in  his  knapsack  a  small  bundle  of 
dressings,  prepared  according  to  a  formula,  then  the 
hospital  stores  could  in  a  great  measure  be  dispensed 
with,  and  with  few  additions  to  the  individual  stock, 
the  wounded  could  receive  careful  dressing.  The 
instruments  and  few  medicines  which  the  infirmary 
would  require  could  then  be  readily  moved  from  place 
to  place,  following  the  line  as  the  din  of  battle  re- 
cedes from  the  points  where  the  fight  had  com- 
menced. 
i. 


138  Ml    INS    OP    TRANSPORTING    THE    WOUNDED. 

The  surgeon  Bhould  examine  the  means  of  trans- 
porting the  wounded  from  whore  they  tall  in  the  field 
infirmary.  These  Bhould  consist  of  at  least  two 
Btretchers  for  every  one  hundred  men  engaged,  al- 
though in  European  ar mien  four  are  allowed  to  each 
company,  besides  light  ambulance  wagons,  spring* 
•  arts,  or  any  other  conveyance  of  transportation,  to 
accommodate  in  the  proportion  of  forty  persons  for 
o very  one  thousand  troops.  The  allowance  of  ambu- 
lance transportation  in  the  Confederate  servico  is  for 
twenty  lying  and  twenty  sitting  por  one  thousand 
men,  added  to  which  arc  five  litters  to  each  regiment. 

The  character  of  the  transport  service  will  depend 
upon  (he  character  of  the  country  in  which  the  war 
is  carried  on.  In  a  level  country,  wagons  are  the 
most  serviceable ;  while  in  hilly  localities,  litters  car- 
ried by  mules  would  lie  the  rnosl  comfortable  trans- 
portation for  the  wounded.  In  Confederate  a-  in 
European  armies,  a  distinct  body  of  men  are  employ- 
ed for  conveying  the  wounded,  so  that  practised 
hands  may  soothe  the  agonies  of  transportation. 
This  is  by  tar  the  most  humane  course,  and,  as  a  mark 
of  civilized  warfare,  should  be  of  universal  adoption. 
It  is  highly  important  that  a  similar  body  be  instruct- 
ed to  act  as  nurses  as  well  as  attend  immediately 
upon  the  wounded,  as  this  timely  assistance  may  save 
many  lives  on  the  field.  In  those  armies  in  which 
this  ambulance  corps  has  not  yet  been  introduced, 
the  regimental  quartermaster,  in  charge  of  the  pio- 
neers and  musicians,  form  a  temporary  body  of  car- 
riers. Besides  the  litters,  each  hearer  carries  a  can- 
teen full  oi  water,  and  the  assistant  surgeon,  who 
follows  the  litters  and  directs  the  transportation,  is 
accompanied   by  two  men   as  orderlies.      One  of  these 

orderlies,  who  habitually  follows  the  medical  officer, 


ORGANIZATION    OF    FIELD    INFIRMARIES.  139 

whether  in  battle  or  on  the  march,  carries  the  hospi- 
tal knapsack.  One  of  the  orderlies  is  armed,  to  pro- 
tect the  party  against  stragglers  and  marauders. 
The  surgeon,  for  a  similar  reason,  should  be  also 
armed  with  a  revolver.  The  orderlies  assist  the  sur- 
geon in  placing  the  Wounded  carefully  in  the  wagons; 
and  also  following  them,  are  at  hand  to  assist  in  un- 
loading the  wagons  at  the  field  infirmary. 

When  the  troops  deploy  or  form  for  action,  the 
surgeons,  with  their  assistants  and  pack-horses,  move 
a  short  distance  to  the  rear,  out  of  the  range  of  the 
shot,  and  they  establish  there  the  field  infirmary.  It 
would  be  convenient  if  some  house  could  be  used  for 
this  temporary  hospital. 

Where  this  can  not  be  had,  the  shade  of  trees  or  the 
shelter  of  a  hill-side  will  answer  the  temporary 
wants  of  the  surgeon.  If  the  body  of  troops  about 
entering  into  battle  is  a  large  one,  with  an  extended 
line,  several  of  these  points  should  be  selected  and 
marked  by  a  suitable  red  flag,  which  designates  the 
spot  where  those  slightly  wounded  can  seek  surgical 
aid.  These  locations  should  be  selected  as  near  as 
possible  to  the  line  of  battle,  so  that  they  may  bo 
easily  reached  by  the  wounded.  They  should  be 
readily  recognized,  protected  from  the  enemy's  fire, 
well  supplied  with  water,  and,  if  possible,  with  straw 
and  shelter  for  the  wounded.  These  sites  should  be 
known  to  the  commanding  officer,  so  that  he  might 
extend  his  orders  to  the  infirmary,  should  it  be  w 
sary,  during  the  fight. 

Before  tin-  medical  army  staff  was  properly  organ- 
ized, and  their  plan  of  WOrk  studied,  so  as  to  render 
the  Btaff  D1081  efficient,  surgeons  accompanied  the 
troops  into  the  fire,  and  took  position  along  the  line 
Of  battle,  where  they  could  give  immediate  succor  to 


140      DUTIES  OF  SURGEONS  OF  FIELD  INFIRMARIES. 

the  wounded.  Experience  Bhowed  them  that,  thus 
isolated  from  each  other,  and  having  no  means  of  car- 
rying with  them  the  various  instruments  which  they 
would  require,  it  was  impossible  to  perform  any  but 
the  most  trivial  operations;  hence  the  necessity  of 
rabling  Burgeons  together  at  4fc  various  field  in- 
firmaries, where,  by  assisting  each  other,  all  the  nec- 
essary operations  may  be  successfully  undertaken 
[nstead  of  each  regimental  surgeon  establishing  Buch 
an  operating  site  for  his  regiment,  the  plan  which  is 
now  adopted  in  the  Confederate  service,  and  which 
has  decided  advantages,  is  to  establish  a  division  or 
corps  field  infirmary,  at  which  all  the  surgeons  of  the 
division  or  corps  concentrate.  The  advantages  of  this 
concentration  are  that  medical  officers  can  always  bo 
found  by  their  commanders,  and  can  assist  each  other 
in  the  care  of  the  wounded.  It  often  happens  that 
but  a  portion  of  the  opposing  troops  are  actually  en- 
gaged in  the  fight.  Under  the  old  plan  of  regimental 
infirmaries,  the  two  medical  officers  of  the  regiment 
engaged  would  have  morelo  do  than  they  could  pos- 
sibly attend  to — the  wounaed  remaining  unattended 
for  hours — while  medical  officers  of  regiments  not  in 
the  fight  would  be  idle.  Now,  by  concentration  ami 
mutual  assistance,  the  wounded  can  he  attended  to  as 
rapidly  as  they  are  brought  in.  The  division  or  corps 
surgeon  establishes  and  directs  the  surgical  affairs  of 
the  field  infirmary,  and  the  ambulances  of  the  division 
are  also  concentrated  at  this  point,  and  thus  offer 
great  facilities  for  removing  rapidly  the  wounded,  as 
soon  as  their  wounds  are  examined,  to  positions  in  the 

rear. 

When  surgeons  combine  at  the  field  infirmaries,  the 
usual  course  is  to  be  operator  and  assistant  in  turn — 
relieving  each  other  when  fatigued.     It  would  be  far 


DUTIES  OF  SURGEONS  OF  FIELD  INFIRMARIES.       141 

better,  however,  to  establish  at  once,  if  possible,  a 
division  of  labor;  lot  there  be  an  understanding  that 
those  best  adapted  by  experience  to  undertake  certain 
duties,  should  confine  themselves  strictly  to  the  same. 
When  each  one  knows  what  role  he  is  to  play,  and 
does  not  interfere  with  others,  a  great  deal  more  work 
can  bo  accomplished  than  where  each  one  acts  inde- 
pendently for  himself.  The  force  of  this  will  appear, 
when  it  is  remembered  that  all  experience  shows  the 
medical  stall'  of  an  army,  however  numerous,  to  be 
always  too  few  on  battle  days.  Remember,  that  all  the 
wounded  must  undergo  a  thorough  examination,  and  all 
needful  operations  should  be  performed  within  twenty-four 
hours,  or  the  wounded  suffer  from  the  neglect.  Now, 
take  into  consideration  the  very  small  surgical  stall' 
of  our  army,  and  the  accuracy  of  fire  of  the  contest- 
ants, with  the  most  approved  and  destructive  arms 
with  very  long  range,  and  wc  will  immediately  sco 
the  necessity  of  economizing  time  and  labor. 

Moreover,  among  the  officers  of  every  brigade  are 
found  Burgeons  of  experience  and  judgment,  but 
among  them  are  also  men  of  purely  theoretical 
knowledge,  just  from  the  schools,  who  always  exhibit 
an  eager  desire  to  use  the  knife,  without  the  judg- 
ment and  experience  necessary  for  deciding  when 
operations  are  required.  Such  officers  can  be  heard 
boasting  of  the  number  of  operations  which  they  have 
performed,  rather  than  the  number  of  cures  which 
thc\  had  obtained.  Many  a  limb  has  been  sacrificed 
to  this  inordinate  thirst  for  operating,  as  many  a 
DH  ve  and  stalwart  soldier  reports  the  safety  of  a  use- 
ful limb  to  his  own  resistance  to  such  indiscriminate 
mutilation.  Such  Burgeons  require  restraint.  After 
every  encounter  the  cases  for  legitimate  operation 
are,  unfortunately,  so  numerous  that   even   the   most 


14_'       DUTIES  <>K    Bl  »F  PIELD  [NFIRMAR1 

ambitions  can,  in  time,  have  their  desire  for  operating 
satisfied.  The  judgment  of  such  officers  should  be 
guided  by  the  experience  of  otheii  ;  and  hence  the 
useful  division  of  labor  at  the  fiold  infirmaries,  into 
who  examine  wounds  and  determine  the  general 
course  ol  treatment  required,  and  those  who  perform 
such  operations  as,  in  the  experience  of  the  board  of 
examiners,  are  necessary  for  the  safety  of  the  wounded. 

The  movements  and  portion  of  the  troops,  and  the 
character  of  the  ground,  must  establish  the  necessity 
for  tlio  greator  or  less  concentration  of  surgeons  at 
the  fiold  infirmaries.  As  the  troops  advance,  they 
arc  followed  by  the  bandsmen  or  litter-bearers,  and, 
it'  the  country  permits  it.  the  ambulance  wagons,  un- 
der charge  of  the  quartermaster  and  assistant  Bur- 
geon, aecompaniod  by  his  orderlies.  These  Btation 
themselves  in  the  roar  of  the  advancing  line,  where 
they  can  distinctly  Bee  what  happens,  and  remove 
immediately,  without  the  range  of  the  shot,  those 
who  may  fall  wounded.  It  is  imperatively  demanded, 
on  the  score  of  humanity,  that  the  wounded  be  re- 
moved from  the  field  of  battle,  with  a>  little  delay  as 
possible,  for  early  treatment.  In  gunshot  wounds, 
above  all  others,  to  obtain  success  early  surgical  as- 
sistanco  is  of  the  greatest  moment.  Therein  is  the 
-reat  advantage  of  having  a  special  transport  corps — 
otherwise  the  excitement  of  battle,  or  the  eagerness 
of  pursuit,  carries  the  line  to  a  distance  from  the 
ground  where  the  battle  tirst  commenced;  and  it  is 
only  after  the  victory  is  achieved  that  the  wounded 
are  thought  of  by  their  comrades,  who.  in  BCOUring 
the  fiold,  find  many  a  dear  friend  whose  life  has  paid 
the  forfeit  of  delay. 

The  practice,  too  frequent  in  our  service,  of  taking 
off  the  surgeon  of  a  regiment  with  a  woundod  officer, 


DUTIES  OF  SURGEON  !  OF  FIELD  INFIRMARIES.      143 

and  leaving  the  command  exposed  to  fire  without 
competent  surgical  aid,  is  an  abuse  of  authority  which 
can  not  bo  too  severely  denounced;  and  any  officer 
should  be  severely  censured  who,  from  selfish  motives. 
would  allow  his  command  to  be  thus  exposed.  An- 
other act  for  censure,  which  should  render  a  surgeon 
liable  to  court-martial  for  dereliction  of  duly,  is  in  so 
far  forgetting  his  position  as  to  assume  the  offensive, 
and  enter  pell-mell  into  the  fight.  The  temptation 
is  strong;  but  among  the  first  lessons  to  be  learned  by 
a  military  surgeon  is  that  of  self-restraint  and  rigid 
attention  (o  those  duties  which  are  connected  with 
his  position.  His  duties  lie  with  the  wounded,  and 
not  in  the  charge.  The  comfort,  if  not  the  lives,  of 
many  are  in  his  keeping,  and  all  unnecessary  exposure 
which  he  voluntarily  incurs  can  hut  be  detrimental  to 
the  service.  In  the  early  campaigns  of  the  war,  sur- 
geons under  fire  often  forgot  their  positions  and  re- 
sponsibilities by  entering  into  the  light.  A  more 
wholesome  discipline  has  altogether  corrected  this 
evil. 

When  our  troops  remain  in  possession  of  the  field, 
the  enemy  having  fallen  hack,  the  surgeons  attached 
to  the  ambulance  corps  should  proceed  without  delay 
to  the  front  of  the  line,  with  all  possible  means  of 
transportation,  to  collect  the  wounded;  and  as  moat 
frequently  night  has  set  in  before  the  enemy  has  yield- 
ed, torches  should  be  carried  by  the  hospital  or 
ambulance  corps,  to  facilitate  this  important  and  hu- 
mane search,  which  is  too  frequently  neglected. 

When  our  army  retreats  ami  our  wounded  have  to 
be  left,  some  of  our  surgeons  should  be  lefl  in  attend- 
ance, and  supplied  with  necessary  dressings — as  no 
dependence  should  he  placed  upon  the  medical  stores 

of  the  enemy,  which  may  be  oxhausted,  or  he  of  an 
inferior  quality. 


CHAPTER   V. 

TrBATWRHT    up    QbBSHOT    WOOBDB— WHAT    Sliori.n   BR    DORR    OH   TBI 

Field  bv  tiik   Assistant  BOROROR  in  command  of  tiik  I.ittkiis — 

TllK.    TllEATMENT   AT    TIIK    FlRLD   [RKRMARY —  IloW    Wnl'NDS  SIIOI.LD 
III:   KXAMINEH. 

When  a  soldier  falls  or  is  wounded  in  battle,  he  is 
at  once  conveyed  by  the  litter-carriers  from  the  line 
of  battle  to  a  short  distance  in  the  rear,  where  the 
assistant  surgeon  looks  at  his  wounds,  applies  tin- 
h:isty  dressing  which  they  require,  and,  placing  him 
comfortably  on  the  litter,  attends  to  his  transporter 
lion.  He  can  do  as  much  for  the  wounded  in  tins 
way  as  if  he  were  actively  engaged  in  operating. 
Should  the  injury  permit  the  wounded  man  to  walk, 
a  compress  and  bandage  is  placed  upon  his  wounds,  if 
thev  be  severe,  and  he  is  directed  to  the  field  infirmary. 
In,  however,  by  far  the  majority  of  cases  of  flesh  wounds 
from  rifle  or  musket  balls,  no  dressings  are  applied  by 
the  surgeon  of  the  ambulance  corps.  The  Avound 
does  not  bleed  much,  and   the  dressings  would   neees- 

sarily  be  so  hastily  put  <>n  and  again  removed  at  the 
field  infirmary,  that  much  saving  of  time  and  material 
is  effected  by  sending  such  cases  directly  to  the  in- 
firmary for  careful  examination  and  appropriate  dress- 
ing. In  those  will)  fractured  limbs,  a  rapid  glance, 
quick  intelligence,  and  an  inventive  turn,  at  once  tells 
the  surgeon  what  is  required,  and  suggests  the  means 
of  effecting  it.  With  a  sword-blade,  a  ramrod,  or  a 
bayonet,  with  a  handkerchief  or  strip  of  cloth,  a  fract- 
ure apparatus  is  at  once  improvised,  and  the  thanks 
of   the    wounded,    now    in  comparative   comfort,   are 


TREATMENT    OF    WOUNDS    ON    THE    FIELD.  145 

freely  bestowed  during  his  transportation  to  the  in- 
firmary or  general  hospital.  If  he  has  a  mangled 
limb,  which  hangs  by  a  very  small  portion  of  the 
soft  parts,  its  separation  should  be  at  once  effected 
b}T  cutting  through  the  mangled  tissues.  Should  he 
be  suffering  much  pain,  which  is  not  usually  the 
case,  the  surgeon,  whoso  pockets  are  well  stored  with 
morphine,  gives  him  an  anodyne  powder,  and  at  onco 
transports  him  to  the  infirmary,  where  the  neces- 
sary operation  is  performed.  If  the  wound  be  an  ab- 
dominal one,  with  protrusion  of  the  intestines,  he 
sees  whether  the^  bowel  is  injured  or  not.  If  not 
injured,  he  returns  it  carefully  within  the  abdomen, 
and  gives  a  large  dose  of  morphine  to  ensure  quiet. 
Should  the  intestine  be  cut  by  the  ball,  he  warns 
the  carriers  and  assistants  from  interfering  until  the 
Abounded  man  be  carefully  transported  to  the  in- 
firmary. Those  wounded  in  the  head,  if  insensi- 
ble, require  veiy  careful  transportation;  the}T  should 
be  as  little  disturbed  as  possible.  Fractured  legs 
give  the  most  trouble  in  transporting  from  the  field, 
as  they  require  the  greatest  care  in  conveying  them, 
safely  to  the  designated  places  for  surgical  treatment, 
it  is  seen,  from  this  rapid  sketch,  that  the  surgeon 
who  follows  the  troops  into  action  has  nothing  to 
do  with  amputations,  resections,  extracting  foreign 
bodies,  etc. ;  these  form  no  portion  of  his  duties.  His 
province  is  solely  to  prepare  tin1  wounded  lor  success- 
ful transportation,  and  beyond  this  he  should  not  in- 
trude his  attentions.  The  great  perfection  of  rilled 
weapons  has  its  influence  upon  the  duties  of  the  field 
Burgeon,  as  the  rapid  and  frequent  changes  of  the 
battle-field  threaten  to  restrict,  within  very  narrow 
limits.  Held  surgery  with  the  ambulance  corps,  and 
necessitate  very  hasty  dressing 

M 


1  |«;  TREATMENT  AT  T 1 1  K  FIELD  INFIRMARIES 

An  eminent  military  surgeon — Mr.  Guthrio— states 
that  bandages  applied  "n  the  (i-  l«l  of  battle  are,  in 
general,  bo  many  things  wasted,  as  they  become  dir- 
ty and  stiff,  and  arc  usually  cul  away  and  destroyed 
without  having  been  really  useful.  There  is  much 
truth  in  this  statement.  Much  of  the  hasty  dressing 
by  the  transport  surgeon  can  very  well  be  dispensed 
with.  As  lie  has  neither  the  time,  nor  is  it  bis  duty, 
to  examine  carefully  the  wounds,  most  of  the  wound- 
ed might  he  sent  on  directly  to  the  field  infirmary 
without  dressing.  The  dressings,  when  removed  at 
the  lidd  infirmary,  are  so  soiled  tha^t  they  are  thrown 
away.  Time,  which  is  so  valuable,  and  also  material, 
which  is  never  in  excess,  bul  most  frequently  defi- 
cient, can  be  saved  by  adopting  this  course.  Only 
in  cases  of  active  hemorrhage  would  it  be  Decessary 
to  apply  compresses  and  the  roller-bandage,  or,  w  hat 
i^  more  rarely  required,  the  tourniquet.  Let  all  other 
-  of  flesh  wounds  receive  their  first  dressing  at 
the  field  infirmary. 

Should  Ihe  soldier  have  a  large  artery  wounded, 
and  the  hemorrhage  be  excessive,  which  is  but  sel- 
dom the  case,  the  Burgeon  should  instruct  the  orderly 
who  superintends  his  transportation  how  to  make 
judicious  finger-pressure.  This  is  much  better  than 
the  tourniquet,  producing  much  less  engorgement  of 
the  injured  tissues. 

d  >vr<j<r)j,  'properly  speaking,  commences  at  the  fit  Id 
infirmary.  Eere  all  wounds  are  thoroughly  exam- 
ined, and  an  accurate  diagnosis  established.  The 
wounds  are  thoroughly  cleansed;  all  foreign  hodies 
which  can  he,  arc  removed,  and  the  first  dressing 
made.  W  the  wounds  are  trivial,  they  arc  dressed, 
and  tic   in,  n  sent  to  rejoin  their  companies. 

When  the  wounds  are  quite  recent,  before  the  tis- 


CLOTHING    DRIVEN    IN    BY   BALL'S.  147 

sues  become  engorged,  there  is  a  temporary  absence 
of  pain  and  a  relaxation  of  the  injured  parts,  which 
favor  an  examination.  The  wound  should  now  bo 
examined  throughout  its  entire  extent  to  determine 
the  presence  of  foreign  bodies,  whether  they  be  balls, 
wadding,  portions  of  clothing,  detached  spiculee  of 
bone,  etc.  For  this  purpose  the  finger  is  the  proper 
probe,  and  should  be  used  on  all  occasions,  with  rare 
exceptions.  It  is  an  intelligent  instrument,  and,  ap- 
preciating what  it  feels,  it  will  not  only  discover  the 
character  of  foreign  bodies  complicating  the  canal, 
but  will  avoid  increasing  the  dangers  by  making  new 
lesions  in  the  depth  of  the  wound.  In  fresh  gunshot 
wounds  the  apertures  which  the  balls  make  arc  large 
enough  to  admit  readily  the  finger  when  introduced 
with  care,  as  the  balls  now  used  in  warfare  are  of 
greater  diameter  than  the  finger.  Very  rarely  is  it 
necessary  to  dilate  a  wound  with  the  probe-pointed 
bistoury  to  assist  in  its  exploration.  The  silver  probe 
is  a  dangerous  and  deceptive  instrument,  and  should  be 
discarded  from  the  battle-field.  Its  use  on  such  occa- 
sions, for  exploring  recent  wounds,  marks  the  novice. 
Halls  are  readily  detected  in  a  fresh  wound,  by 
placing  the  patient  in  the  position  in  which  he  re- 
ceived the  injury,  if  the  direction  from  which  the  ball 
came  be  known.  Portions  of  clothing  and  wadding 
are  detected  with  greater  difficulty.  Before,  how- 
ever, probing  the  wound  for  the  detection  of  foreign 
bodies,  be  quite  sure  that  the  clothing  of  the  soldier 
has  been  perforated.  Often  a  single  orifice  is  seen 
leading  into  a  limb  without  exit,  which  would  at  OHCO 
Suggest  an  embedded  ball;  when  an  examination  of 
the   clothing   would    show   thai     the    ball     had    driven 

tln-sc  inio  the  wound  without  sufficient  force  to  trans- 
fix them.  and.  on    removing  hastily   the  clothing,  the 


1  18  CLOTHING    DRIVEN    in    r.Y    BA1  ' 

ball  had  been  extracted  by  this  diverticulum  pushed 
in  before  it.     This  examination  of  the  clothing  will 
much  time  t<>  the  Burgeon,  and  painful,  protract- 
ed, injurious  probing  t<>  the  wounded. 

Among  the  wounded  Federalists  from  the  Battle  of 
Manassas  in  the  general  hospital  at  Richmond,  ;i  case 
came  under  my  observation  which  well  exemplified  the 
necessity  of  observing  this  rule.  It  was  that  of  a  Ger- 
man who  had  heen  shot  in  the  head,  over  the  left 
parietal  bone.  As  the  scalp  was  wounded  and  the 
bones  crushed,  the  escape  of  fragments  during  the 
treatment  left  an  opening  through  which  the  pulsa- 
tions of  the  1 1 rain  could  be  readily  discerned.  As  thi 
was  no  counter-opening,  the  conclusion  was  entertain- 
ed that  the  ball  had  entered  the  skull,  and  was  now 
lying  embedded  in  some  portion  of  the  brain.  The 
case  was  exhibited  as  one  of  those  rare  instances  in 

which  a  foreign  body  Could  remain  in  contact  with  the 
I n-ain  without  producing  cerebral  disturbance.  It  was 
not  until  some  week-s  after  admission  that  his  cap  was 
examinod,  when  it  was  found  indontod  and  stiffened 
with  blood,  showing  that  it  had  heen  pushed  into  the 
wound  before  the  ball.  The  cap  had  been  slightly  cut 
by  the  sharp  edge  of  bone  from  the  pressure  of  the  hall, 
but  there  was  no  opening  sufficiently  large  to  permit 
a  ball  to  pass.  An  earlier  examination  of  the  cap 
would  have  robbed  the  case  of  much  of  its  interest. 

When  the  shirt  or  drawers  are  not  torn,  no  foreign 
body   can    have    lodged    in   the   flesh    which  they    were 

covering.     Prom  the    nature   of  recent   wounds,  tin' 

examination  and  removal  of  all  foreign  bodies  will 
be  more  easily  accomplished,  and  with  f'ss  pain  and 
danger  to  the  wounded,  when  undertaken  at  an  early 
period.  This  should  be  done  carefully,  thoroughly, 
and  witle. ui  delay 


REPORT  OF  EXAMINATION  SENT  WITH  WOUNDED.    149 

A  Tegular  report  should  be  kept  of  all  the  cases 
dressed  at  the  field  infirmary,  and  a  brief  description  of 
each  case  should  be  sent  on  with  the  patient  to  the  gen- 
eral hospital;  so  that  if  proper  officers,  in  whose 
judgment  the  hospital  staff  can  confide,  had  previously 
examined  thoroughly  the  wound  and  sent  on  their  re- 
port,  no  further  examination  would  be  needed.  The 
pinning  a  paper  to  the  coat  of  the  wounded  when  he  is 
conveyed  from  the  infirmary,  upon  which  is  written 
the  history  of  the  wound,  saves  time  and  trouble  at  the 
regular  hospital,  and  relieves  the  patient  from  much 
unnecessary  pain.  If  the  surgeon  be  trustworthy,  his 
diagnosis  should  be  respected,  and  no  further  investigation 
permitted.  Many  serious  cases  can  be  protected  from 
annoyance  and  further  injury  by  adopting  this  simple 
expedient.  In  many  cases  this  is  the  only  examina- 
tion Which  the  wound  will  need. 

The  neglect  or  insufficiency  of  the  first  examination 
is  often  the  after-cause  of  the  loss  of  a  limb,  and  even 
life.  After-examinations  heighten  irritation  and  in- 
flammation in  the  wound,  and,  as  they  permit  air 
(which  ought  to  be  rigorously  excluded)  to  pass  to  the 
bottom  of  the  wound,  this  promotes  the  decomposition 
of  the  extravasated  fluids  and  exudations,  induces 
suppuration  and  sloughing,  and  predisposes  to  pyaemia, 
with  its  fatal  sequelae.  Many  a  limb  and  life  would  be 
preserved,  if  the  examination  of  gunshot  wounds  could 
be  limited  to  the  battle-field;  and  military  surgery 
will  have  attained  great  perfection  when  a  thorough 
diagnosis  is  obtained  by  this  first  examination. 

The  extent  and  nature  of  gunshot  wounds  are  often 
ascertained  at  a  glance.  Touching  a  limb  may  be 
sufficient  to  indicate  to  the  experienced  Burgeon  the 
extent  ami  character  of  tin-  wound,  and  suggesl  the  ap- 
propriate treatment  ;   while  other  wound.-,  as  those  in 


150    REPORT  OF  EXAMINATION  BENT  WITH   WOUNDED. 

the  neighborhood  of  joints,  may  require  all  the  skill  and 
scrutiny  of  the  most  experienced  to  obtain  a  satisfac- 
tory diagnosis,  Xo  haste  should  be  permitted  in  this 
examination,  to  the  injury  of  the  wounded,  through  m 
carelessness  of  diagnosis.  Should  large  arteries  be  in- 
jured, they  should  be  ligated  always  in  situ  abovi  ■ml 
below  the  point  injured,  and  for  this  purpose  the  wound 
must  be  enlarged. 

A.s  a  general  rule,  torn  tissues  will  reunite,  while 
bruised,  crushed  tissues  slough.  All  wounds  in  which 
a  probability  exists  of  union,  by  the  first  intention, 
should  be  nicely  adjusted  by  adhesive  plaster.  The 
great  inconvenience  of  the  ordinary  diachylon  plaster, 
which  requires  heat  to  make  it  adhere,  must  exclude 
it  from  field  service.  The  Husband's,  or  isinglass  phis. 
ter,  is  much  more  easily  applied,  requires  no  heat — a 
little  moisture  being  all  that  is  needed— is  not  injured 
by  hot  weather,  and  when  closing  a  wound,  gives  as 
much  support  as  the  diachylon.  It  also  excludes  com- 
pletely the  air,  with  its  injurious  influences,  which  is 
not  its  least  advautage.  Diachylon  plaster  is  rather 
required  for  hospital  practice,  where  it  is  used  to  dress 
suppurating  stumps,  from  which  the  continued  dis- 
charge of  pus  would  loosen  strips  of  isinglass  plaster. 

Should  a  limb  he  so  injured  that  joints  are  largely 
Opened  into,  main  blood-vessels  and  nerves  torn 
through,  soft  parts  extensively  lacerated,  or  a  limb 
flayed,  then  amputation  should  follow  immediately  the 
condemnation   of  the   limbj   held  surgery   here  proves 

itself  the  only  successful  surgery,  as  all  statistics 
clearly  show,  [f  the  limb  is  simply  fractured,  without 
injury  to  the  main  hlood-ves  ids  and  nerves,  and  with- 
out complications  with  joint  injuries,  the}*  should  he 
considered  simple  fractures,  and  dressed  as  such  at  the 
field  infirmary.     If,  in  connection  with  a  condemned 


REPORT  OP  EXAMTNATrON  SENT  WITH  WOUNDED.    151 

limb,  other  mortal  injuries  exist,  the  impropriety  of 
performing  an  amputation  is  clearly  seen,  and  surgeons 
must  not  be  seduced  from  this  course  by  fondness  for 
operating.  When  joints  are  crushed,  or  the  heads  of 
bones  perforated,  resections  are  urgently  demanded, 
and  should  be  performed  before  violent  reaction  takes 
place. 

It  is,  of  coarse,  understood  that,  although  wounds 
might  be  examined,  foreign  bodies  removed,  and  the 
Wound,  if  simple,  dressed  while  a  soldier  is  Buffering 
under  shock,  no  serious  operation,  which  would  still 
further  depress  the  nervous  powers,  or  cause  a  further 
loss  of  blood,  should  be  performed  until  extreme  de- 
pression subsides.  Although  the  nervous  shock  accom- 
panies the  most  serious  wounds,  it  may  often  be  met 
with  in  the  most  trivial  injuries.  It  is  recognized  by 
the  sufferer  becoming  cold,  faint,  and  pale,  with  the 
surface  bedewed  with  a  cold  sweat.  Tiie  pulse  is  small 
and  flickering;  anxiety  and  mental  depression  is  also 
present,  with,  at  times,  incoherence  of  speech.  Often 
this  shock  is  very  transient  when  accompanying  sim- 
ple wounds.  A  drink  of  water  and  a  few  encouraging 
words  may  lie  sufficient  to  dispel  it.  When  it  persists, 
even  where  the  injury  appears  trivial,  it  forebodes 
trouble,  and  a  more  careful  examination  may  detect  a 
fatal  injury.  It  is  the  duration,  more  than  the.  degree 
of  shock,  which  marks  the  serious  character  of  the 
wound;  and  when  this  constitutional  alarm  persists, 
there  is  great  tear  that  hidden  mischief  is  lurking,  and 
irgeon  should  l>e  very  guarded  in  his  opinion  of 
the  case.  Keeping  the  patient  warm,  in  the  recumbent 
posture,  with  blankets  and  hot  bottles,  administering 
wine,  brandy,  whiskey,  <>r  ammonia,  hartshorn  to  the 

nostrils,  frictions   and   cataplasms   to    the   extremities, 

is  the  course  pursued  to  restore  nervous  energy. 


152         TRANSPORTATION    TO   GENERAL    HOSPITAL. 

In  all  painful  operations  chloroform  Bhould  be  freely 
administered  to  produce  the  desired  anaesthesia.  Like 
all  valuable  medicinal  agents  which,  when  taken  in 
overdoses,  are  poisonous,  it  can  remove  Buffering  <>r 
destroy  life  according  t<>  its  administration.  The 
Crimean,  Italian,  and  Confederate  wars,  in  recording 
tin-  advantages  ot  chloroform  in  field  surgery,  show  it 
to  be  now  one  of  the  indispensables  for  successful  prac- 
tice. It  saves  the  lives  of  many  wounded,  who  would 
perish  from  the  shock  of  a  second  operation  ;  and  also 
many  who  would  have  been  considered  as  without  the 
pale  of  surgical  art  can  now,  thanks  to  this  invaluable 
remedy,  be  benefited  by  surgery. 

In  our  country  railroads  traverse  every  portion  of 
the  states,  and  as  battles  usually  occur  in  the  imme- 
diate neighborhood  of  thoroughfares  between  large 
cities,  it  is  not  improbable  that  they  will  be  found  in 
the  immediate  vicinity  of  battle-fields.  If  such  be  the 
case,  a  sufficient  number  of  ears  should  be  kept  in 
readiness  for  the  use  of  the  wounded.  Transport 
wagons  are  in  constant  communication  with  the  field 
infirmaries.  As  the  wounded  are  attended  to,  they 
should  not  bo  allowed  to  accumulate  around  the  infirm- 
ary, hut  be  sent  off  at  onee  to  the  nearest  '  railroad 
station,  from  whence  they  will  he  distributed  in  the 

towns  nearest  to  the  scene  of  action.  General  hospi- 
tals should  have  heen  previously  prepared  in  these 
localities  for  the  reception  of  the  wounded;  and  here 
the  regular  treatment  commences. 

Daring  a  general  engagement  each  field  infirmary 
should  he  in  constant  communication  with  this  general 
temporary  hospital  which  the  medical  director  has 
located, and  as  soon  as  the  wounded  are  examined  and 
dressed*,  they  should  lie  sent  without  delay  to  this 
point.     This  allows  the  field  infirmary  to  change  its 


TRANSPORTATION    TO    GENERAL    HOSPITAL.  153 

position,  and  to  follow  the  division  to  which  it  is 
attached.  If  this  transportation  of  the  wounded  be 
properly  attended  to,  no  wounded  should  be  left  by 
night  at  the  field  infirmaries. 

By  not  allowing  an  accumulation  of  wounded  at 
field  infirmaries  we  avoid  confusion,  and  prevent  our 
men  from  being  made  prisoners,  should  there  be  a  re- 
verse of  our  arms  and  an  advance  of  the  enemy  upon 
the  site  of  our  field  hospitals.  Should  the  ambulance 
wagons  not  be  sufficient  to  transport  the  wounded, 
wagons,  carts,  carriages,  and,  in  fact,  every  species  of 
vehicle,  should  be  impressed  from  the  neighboring  in- 
habitants, so  as  to  ensure  for  the  wounded  a  place 
of  safety  and  comfort. 

If  it  be  convenient  for  the  wounded  to  reach  the  gen- 
eral hospital  within  twenty-four  hours  from  the  recep- 
tion of  their  injuries,  many  serious  cases  lor  operation, 
such  as  the  resections,  might  well  be  deferred  from  the 
field  infirmaries  until  the  wounded  have  arrived  at  the 
station  where  that  quiet  and  rest,  with  medical  com- 
forts, which  are  so  necessary  for  a  successful  result, 
can  be  obtained.  When  the  wounded  are  brought  to 
the  field  infirmary  they  are  not  attended  to  in  the  or- 
der in  which  they  arrive.  Those  most  seriously  injured 
always  receive  the  earliest  attention,  officers  and  sol- 
diers awaiting  their  turn.  If  the  trivial  accidents  had 
been  dressed  upon  the  field,  they  should  pass  directly 
on  toward  the  railroad  or  the  general  hospital,  without 
stopping  at  the  field  infirmary. 

The  common  dressings  which  all  gunshot  wounds 
receive  is  a  wet  cloth,  covered,  if  possible,  with  a  piece 
of  oiled  sillc  or  waxed  cloth,  and  secured  with  a  single 
turn  of  the  roll  of  bandage.  This  keeps  the  wound 
moist,  and  is  the  most  soothing,  comfortable,  efficient, 
and   simple  dressing  which  can    be  devised.      By  wet- 


154  rO   BE  LEFT  WITH  THE  WOUNDED. 

ting  the  outer  bandage,  the  cold  produced  by  evapora- 
tion is  transmitted  through  t<>  the  wound,  while  the 
oiled  silk  keeps  the  parts  moist.  When  oiled  or  itidia- 
rubber  cloth  <:m  not  be  obtained,  and  no  facilil  ies  exisl 
for  keeping  the  wound  constantly  wet  while  the 
patient  in  being  transported  to  the  general  hospital,  a 
cloth  well  greased  with  olive  oil  is  the  best  substitute 
for  the  wet  dressings.  Many  ragged  wounds  may 
have  their  edges  pared  oil' and  then  brought  together; 
with  every  prospect  of  a  speedy  union,  provided  the 
after-treatment  with  cold  dressings  is  judiciously  fol- 
lowed. 

It  is  understood  that  all  those  who  can  he  conven- 
iently moved,  should  he  transported  at  the  earliest 
possible  moment  to  general  hospitals,  established  in 
contiguous  towns,  should  there  be  no  facilities  for 
this  transportation,  or  the  serious  character  of  the 
wound     render    transportation    dangerous,     then    any 

in  the  neighborhood  contiguous  to  tin"  battle- 
field must  he  used  as  a  temporary  hospital  for  the 
treatment  of  such  seriously  wounded,  whose  safety  de- 
pends upon  absolute  quiet,  rest,  and  careful  nursing; 
or  tents  can  be  pitched  for  the  temporary  accommoda- 
tion of  such  patients. 

Should  the  army  ad  vancc/t  he  regimental  suigvons 
must  follow  their  com  m and s.  leaving  either  an  assistant, 
or  an  extra  medical  attendant   for  the  wounded  —it  bo- 

ing  pretkimed  that  a  reserve  modicar^corps  had  been  at- 
tached to  the  army  for  extra  or  reserved  duty,  when 
it  was  known  at  head-quarters  that  a  battle  was 
expected.  These  reserve  surgeons  will  make  vwvy 
preparation  for  the  comfort  and  accommodation  of  the 
wounded.  Should  the  army  unfortunately  meet  with 
a  reverse,  all  available  means  of  transportation  must 
he    pr08Sed    into    the    service     for    the    removal    of   the 


SURGEONS  TO  BE  LEFT  WITH  THE  WOUNDED.        155 

wounded  to  the  rear,  and  fchey  must  he  sent  off  as 
speedily  as  possible.  If  this  had  been  attended  to  from 
the  commencement  of  the  engagement,  (here  would  In- 
fewer  to  remove  later  in  the  day,  when  a  retreat  was 
compulsory.  No  wounded  soldier,  whose  injuries  are 
so  slight  that  he  can  walk,  should  ever  he  carried,  as 
he  takes  up  a  place  in  the  transport  wagon  which  ex- 
cludes one  who  can  not  assist  himself. 

There  are  many  cases  df  injury  to  which  long  trans- 
portation would  be  certain  death.  If  the  general 
hospital  can  not  be  conveniently  reached,  such  cases 
must  be  treated  at  some  farm-house  contiguous  to  the 
field  of  battle;  and  if  troops  are  compelled  to  retreat, 
humanity  dictates  that  the  severely  wounded  should 
always  be  left  to  the  enemy,  with  a  sufficient  number 
of  surgeons  and  competent  nurses  to  look  after  their 
wants.  When  left  without  surgeons,  they  arc  always 
neglected,  and  man}''  lives  may  be  sacrificed  for  want  of 
that  immediate  attention  which  the  enemy's  surgeons 
must  first  give  to  their  own  wounded,  and  which 
precious  time  can  never  be  recovered.  This  becomes 
especially  urgent  where  the  nations  at  war  speak 
different  languages.  The  rule  now. recognized  in  civ- 
ilized warfare  is,  always  to  leave  competent  surgeons 
with  the  wounded  who  are  left  to  be  cared  for  by  the 
enemy.  Such  surgeons  and  nurses  being  always  con- 
sidered as  non-combatants  by  a  civilized  enemy,  are. 
allowed  to  return  to  their  corps  as  soon  at  their 
services  can  he  dispensed  with,  without  detriment, 
to  the  wounded  prisoners. 

The  following  excellent  advice  is  offered  by  Dr. 
Millengen  to  surgeons  who  may  be  placed  in  such 
trying  conditions  :  ''When  surgeons  are  thus  placed  on 
duty  with  an  enemy,  they  must  bear  in  mind  tliat  the 
welfare  of  our  wounded  will,  in  a  great  degree,  depend 


SB    DO  Bl    i.i  ir  WIN  I  THE  WOUNDED. 

upon  1 1n-  propriety  ofthoir  conduct.  No  irritation  of 
mind  from  disappointment,  n<>  national  feeling,  should 
induce  there  to  enter  into  unpleasanl  discussions. 
They  should  especially  endeavor  to  cultivate  a  friend* 
ly  intercourse  with  their  medical  brethren,  carefully 
avoiding  altercations  <>n  professional  points,  in  which 
in- .st  probably  they  may  differ.  A  deviation  from  this 
prudential   course    has    often    proved    the    soun 

jealousies    and   animosities,  from   which    the   wounded 

ultimately  suffered.  When  the  enemy's  wounded  are 
numerous,  and  their  surgeons  are  not  in  sufficient 
numbers  to  attend  to  them,  wo  sho.ihl  invariably  vol- 
unteer our  assistance,  should  our  duties  afford  us 
leisure.  Such  a  line  of  conduct  is  ever  appreciated; 
and  can  not  tail  to  lead  to  ultimate  reciprocal  advan- 
tages and  good  feeling."* 

Article  Ambulance,  in  Costello'a  Cyclupajdia  of  Practical  Surgery. 


CHAPTER   VI. 


The  character  op  Gunshot  Wounds — Orifices  of  ENTRANCE  and 
exit — Primary  Hemorrhage — Natural  II.ematosis — Tourni- 
quets HUT  SELDOM  REQUIRE!*  IN  Surgery — HOW  HEMORRHAGE  I  OH  - 
TROLLED — Examination  of  Wound  for  Foreign  Bodies  should 
only  ile  done  once,  rut  that  thoroughly  and  as  soon  as  possible 

after   the  accident tl!e    hlstory    of   the    case   important-- 

Lodging   Foreign   Bodies  always    give  trouble,    even   years 

after    injury gunshot  wolnds  do  not  require   dilatation 

Necessity  of  Examining  the  Pulsations  of  the  Main  Artery 
below  the  Wound  for  suspected  injury — Ligation  of  the  open 
Mouths  of  the  Artery  the  Rule  of  Practice — Water-dressing 
the  only  rational  Treatment  of  Gunshot  Wounds  ;  its  adyan- 
tages  oyer  all  other  applications — Secondary  Hemorrhage, 
how-  treated — General  or  Constitutional  Treatment  of  Gun- 
shot Wounds. 

Appearance  of  Gunshot  Wounds. — AVc  have 
already  stated  that  the  more  perfect  and  destructive 
arms  now  in  use  in  modern  warfare,  and  the  variety, 
form,  and  size  of  missiles,  have  modified  materially  the 
Symptoms  and  march  of  gunshot  wounds.  From  the 
effects  of  a  cannon  shot  weighing  six  hundred  pounds 
to  the  ounce  ball  of  an  Enfield  rifle,  a  small  fragment 
of  shell,  or  still  smaller  buckshot  thai  enters  into  the 
musket  cartridge,  we  see  every  possible  variety  of 
wounds,  both  as  to  extent  and  severity,  although  die 
cases  of  gunshot  injury  requiring  treatment  are  usual- 
ly from  rifle  or  musket  balls,  or  small   fragments  of 

shell. 

Large  round  cannon  hall  have  nearly  Itch  discard- 
cd  from  modern  warfare,  and  the  pyramidal  piles 
which   forVnerl  I  nil  arsenals   have  now 


158      At Ti.Ali.W'l-:  OF  GUNSHOT  WOUNDS. 

place  i<>  elongated  shol  and  bolts  of  three  times  the 
former  weight  of  metal,  which  are  ejected  from  rifled 
cannon  with  frightful  velocity  and  wonderful  preci- 
sion, whon  even  at  a  distance  of  nearly  five  miles. 
When  these  huge  missiles  strike  the  trunk  they  cnt 
the  body  in  two,  and  wnon  they  impinge  upon  ;i  limb 
they  sweep  all  resisting  tissues  before  them  in  their 
onward  career,  leaving  an  irregular,  blackened  pulpi- 
fied  Btamp,  in  which  detritus  of  bonea  and  muscle,  with 
coagulated  blood,  form  an  amalgam  of  lifeless  tissue, 
which  the  surgeon  must  remove  by  amputation.  'The 
torn  blood-vessels, however  large, do  not  usually  bleed 
in  such  n  stump.  A  spent  ball  of  heavy  weight  will 
disorganize  the  subcutaneous  tissues,  crushing  the 
bones,  although    the    tOUgh    elastic    skin   may    remain 

unbroken.  Extensive  echimosis  appearing  after  a  tew 
hours,  indicates  the  severity  of  the  injury. 

Fragments  of  shell  from  ten   and  twenty  pounder 

guns,  which  are  the  calibre  of  field-pieces,  make  Xi'vy 
ugly  wounds;  and  where  they  do  not  impinge  against 
hone-,  tear  dow  n  the  tissues,  leaving  extensive  suppu- 
rating surfaces  which  heal  very  slowly.     When  they 

bury  themselves  in  a  limb,  the  wound  which  they 
make  is  irregular, often  elongated, and  usually  smaller 
than  the  diameter  of  the  fragment  embedded. 

The  conical  shot,  with  its  excessive  momentum, 
tram-fixes  the  tissues  with  groat  rapidity,  usually  pass- 
ing directly  through  the  soft  parts,  rarely  burying 
themselves,  and  when  not  impeded  in  their  transit  by 
very  resisting  media,  the  two  orifices  of  entrance  and 

exit  which  they  leave  vary  hut  slightly  in  their  ap- 
pearances. 

The  entrance  made  by  a  conical  hall  in  the  skin  is 
more  or  less  oval,  depending  upon  the  contraction  and 
ret  i  action  of  t  he  skin,  and  sometimes,  although  rarely, 


^^^^    ORIFICES    OF    ENTRANCE   AND    EXIT.  159 

it  presents  even  a  linear  appearance  resembling  an 
incised  wound.  When  the  conical  ball, entering  point 
foremost,  and  meeting  some  resistance  in  its  course 
through  tlie  tissues,  is  either  changed  in  form  or  is 
turned  upon  its  side,  the  orifice  of  exit  is  found  very 
large  and  irregularly  torn,  with  the  surrounding  tis- 
sues much  bruised. 

Balls,  whether  round  or  elongated,  usually  make  an 
irregularly  rounded  entrance,  surrounded  by  discol- 
ored, depressed,  inverted  tissues — these  having  been 
evidently  mashed  or  crushed  by  the  ball  prior  to  its 
entrance,  and  the  skin  drawn  in  to  a  certain  extent 
with  it.  When  the  ball  is  moving  with  great  velocity 
the  orifice  of  entrance  may  be  more  or  less  round, 
with  loss  of  skin,  and  the  edges  smoothly  cut,  without 
depression  or  inversion  of  its  margins.  The  tissues 
around  the  orifice  of  exit  are  lacerated,  usually  more 
or  less  protruding,  and  the  orifice  probably  larger,  and 
more  irregular  than  where  the  ball  entered.  These 
two  orifices  are,  however,  modified  in  appearance  by 
so  many  circumstances — the  form,  size,  velocity,  ami 
number  of  the  missiles;  changes  in  the  missile  after 
its  entrance  into  the  body  and  prior  to  its  escape;  the 
distance  of  the  wounded  person,  his  position,  his  cloth- 
ing, foreign  bodies  winch  may  have  been  about  his 
person,  and  driven  before  the  ball,  etc., — that  in  some- 
cases,  without  the  history  of  the  accident  from  the 
patient  or  those  who  saw  the  occurrence,  it  would  be 
difficult  to  determine  which  opening  was  first  made. 

The  effects  produced  by  the  action  of  the  ball  upon 
the  tWO  orifices  can  be  easily  understood  when  it  is  re- 
membered that,  in  entering,  the  tissues  which  are 
being  perforated  are  supported  by  the  entire  thickness 

of    the    limb,   SO    that    often    (he    |»;l||    appeals    to    have 

carried  before  it  a  piece  ■•(  flesh  which  it  had  out  out 


160  OR!  KICKS    OF    ENTRANCE    AND    EXIT. 

as  by  a  'lie,  and  hence  the  more  or  less  rounded  form 
of  this  opening.     After  traversing  the  limb,  in  making 

its  exit,  the  tissues    through   which  the  hall    is  now 
pushing  have  no  support.     They  are  stretched  inordi- 
nately before  they  arc  torn,  hence  the  oversion  of  the 
edges  and   the  flap-like  lacerations  of  this  exit,  with 
sometimes  nothing  more  than  a  rent  or  split  in  tho 
skin.     Observing  field  surgeons  have  noticed  that,  in 
examining    recent    wounds,    the    finger    in    passing 
through  the  orifice  of  entrance  traverses  a  compara- 
tively smooth  channel  in  the  same  direction  with   the 
inverted  tissues.     When  the  finger,  on  the  contrary, 
is  thrust  in  at  the  orifice  of  exit,  a  sensation  of  rough- 
ness is  experienced  as  the  ends  of  the  inverted  tis- 
sues are  encountered.    The  direction  of  these  inverted 
tissues,  like  splinters  of  wood,  all  running  one  way, 
can,    by    careful    manipulation,    be    used-  in    recent 
wounds   to   assist   in    establishing  a  diagnosis.     En- 
gorgement of  the  tissues  will  mask,  and  suppuration 
completely  efface,  all  traces  of  direction  of  the  soft 
filaments.     If  a   bone  has  been  shattered,  the   direc- 
tion of  the  spiculse  will  always  determine  the  direc- 
tion  of  the  missile,  as  they  are  invariably  driven   in 
front   of  the    ball.     All  who    are    familiar    with    the 
driving  of  a  nail  through  a  board,  or  firing  at  the  same 
with  a  pistol,  will  see  a  rough  working  of  this  princi- 
ple.    These  peculiarities   are,   at   times,  so   stamped 
upon   the  clothing  that,  by  an  examination  of  them 
alone,  a  diagnosis  can  be  established. 

It  is  often  of  consequence  to  determine  the  character 
of  these  apertures,  so  as  to  distinguish  between  a 
traversed  ball,  with  its  two  orifices,  or  two  balls  em- 
bedded. It  must  not  be  forgotten  that  one  ball  may 
make  several  openings,  by  the  hall  being  divided  in 
the  limb  upon   a  sharp  crest  of  bone.     <  'ases  are  not 


FLATTENING  OF  BALLS.  1(51 

very  rare  in  which  a  portion  of  a  ball  may  pass  out,  a 
fragment  remaining  behind.  A  single  ball,  by  splitting 
in  this  way  against  some  obstacle  in  the  flesh,  has  been 
known  to  break  into  six  pieces,  each  in  exit  making  a 
corresponding  wound. 

In  removing  balls,  whether  conical  or  round,  from  a 
limb,  most  frequently  indentations  are  seen  upon  their 
flattened  sides — imprints  of  the  opposing  tissues  which 
had  offered  the  greatest,  resistance  to  their  onward 
progress.  Very  often  are  such  balls  irregularly  mash- 
ed, and  sometimes  completely  flattened,  as  if  beaten 
out  by  heavy  blows  bet  ween  two  hard  plates.  "When 
impinging  against  an  osseous  spine,  or  even  a  tendon, 
I  have  seen  a  ball  which  presented  tho  appearance 
as  if  a  wedged-shape  piece,  involving  one-fifth  of  its 
substance,  had  been  cut  out  by  some  smooth,  sharp 
instrument;  and  I  have  also  seen  balls  completely 
divided  by  meeting  a  similar  obstacle.  It  has  been  the 
habit  to  account  for  these  changes  in  form  and  the 
mashing  of  balls  by  their  striking  upon  some  hard,  re- 
sisting body  before  entering  the  tissues — as  a  tree,  a 
wall,  the  gun  of  a  neighboring  comrade,  etc.;  but  very 
frequently  we  remove  flattened  balls  from  persons 
when  no  such  explanation  can  be  accepted.  In  these 
cases  we  are  forced  to  seek  other  causes  for  this 
flattening  of  the  missile,  which  we  can  only  explain  by 
an  increased  temperature  in  the  ball,  the  result  of 
friction  and  heat  transmitted  from  the  ignited  charge, 
which  renders  the  metal  so  malleable  as  to  receive  im- 
pressions from  comparatively  soft  bodies.  Those  who 
have  observed  the  moulding  of  bullets  must  often  have 
been  struck  with  the  little  force  requisite  to  cut  off  the 
necks  of  a  dozen  at  a  time  while  warm  in  the  moulds. 
But  let  the  ball  cool,  and  the  separation  of  a  single 
neck  of  lead  from  the  round  mass  becomes  a  serious  un- 

N 


lt'.'2  DEVIATION    OF    BALLS. 

derbaking,  requiring  a  very  heavy  blew.  May  ool 
this  increased  temperature  of  a  ball  alsoexplain  other 
phenomena  connected  with  gunshot  wounds,  viz:  the 

burning  sensation  imparted  by  a  ball  traversing  the 
tissues,  the  sensitive  nerves  magnifying  its  tempera- 
ture, etc.  ? 

Conical  halls  show  much  less  deviation  than  round 
halls.  They  usually  take  a  straight  course,  ploughing 
through  all  opposing  structures — nothing  resisting  the 
penetrating  force  of  these  projectiles.  They  seldom 
follow  the  contour  of  bones,  as  the  round  often  do,  but 
at  once  crush  them — their  double  weight  and  increas- 
ed velocity  making  many  more  fractures  than  the 
round  ball  of  former  wars.  This  perforating  proporty 
of  conical-cylindrical  halls,  which  is  now  the  common 
form  of  rifle  missile,  depends  more  upon  its  moment  urn 
than  its  shape,  which,  when  placed  under  the  same 
condition  with  a  round  ball,  would  be  even  more 
likely  to  be  diverted  from  a  straight  course  by  resisting 
media.  This  divergence  of  conical  shot  is  strikingly 
exemplified  in  ricochet  firing  over  water.  The  heavy 
conical  shot  are  found  to  be  so  readily  diverted  as  to 
destroy  the  efficacy  of  ricochet  firing,  which,  with 
round  ball,  is  very  destructive.  On  this  account  elon- 
gated conical  balls,  from  rifle  cannon,  arc  only  effec- 
tive when  fired  directly  at  an  object.  When  conical 
balls  are  carelessly  made,  they  assume  every  possible 
position  in  their  flight,  and  when  fired  at  a  target  are 
found  to  strike  with  their  side  as  often  as  with  the 
point. 

In  spite  of  the  rapid  passage  of  even  conical  balls, 
some  of  the  tissues,  through  their  toughness  and  elas- 
ticity, often  escape  direct  injury  from  them.  Arteries 
come  under  this  head.  Owing  to  their  peculiar  struc- 
ture, cylindrical  form,  and  loose  connections,  lying  in 


SYMPTOMS    OF    GUNSHOT    WOUNDS.  163 

a  bed  of  very  loose,  cellular  tissue,  which  permits  of 
considerable  movement,  they  often  escape  transfixion, 
when  their  position  lies  evidently  in  the  direct  course 
of  the  ball.  Every  army  surgeon  has  seen  numerous 
oases  of  gunshot  injuries  about  the  root  of  the  neck, 
where  balls  had  traversed,  in  every  conceivable  direc- 
tion; in  some  cases  antero-posteriorily — in  others  later- 
ally— going  deeply  through  the  soft  parts,  yet  picking 
their  way,  as  it  were,  with  such  care  as  to  avoid  the 
great  vessels  among  which  the  missile  had  channelled 
its  course.  So  great  is  this  power  of  avoiding  perfora- 
tion in  the  large  arteries,  that  rarely  does  death  take 
place  on  the  battle-field  from  division  of  the  large 
vessels  of  the  extremities  by  bullets. 

Phenomena  accompanying  Gunsiiot  Wounds. — It 
has  often  been  noticed  by  hospital  surgeons  that,  under 
treatment,  wounds  from  certain  battle-fields  assume 
peculiar  phases,  which,  at  other  times  and  under  other 
circumstances,  they  do  not  exhibit.  I  have  often 
heard  it  remarked  by  army  surgeons  that  the  wounds 
from  the  several  battles  before  .Richmond,  viz:  those 
of  the  26th,  27th,  20th,  and  80th  of  June,  and  1st  of 
July — exhibited  a  marked  disposition  to  slough;  while, 
those  from  other  battle-fields  would  heal  up  with  great 
readiness,  the  majority  of  those  sent  into  hospitals 
not  being  retained  more  than  a  few  da}'s.  This  con- 
dition of  sloughing,  wit li  its  direful  accompaniments 
of  secondary  hemorrhage,  etc.,  can  bo  traced  to  the 
combined  effects  of  many  depressing  causes.  In  those 
wounded  during  the  battles  about  Richmond,  we  find 
a  ready  solution  in  the  bad  condition  of  the  troops, 
owing  to  the  enervating  influences  of  camp  diseases, 
viz:  measles,  typhus,  and  malarial  fevers,  etc.;  added 
to  which, our  troops  were  very  badly  clothed  and  badly 


1G4  HEMOBRHAQB    IN    0UN8HOT   WOUNDS. 

fed,  often  subsisting  upon  one-quarter  rations;  the 
weather  very  inclement,  with  continued  rains  \  and  our 
troops  morally  depressed,  by  being  forced  back  by 
overwhelming  numbers  t«>  cover  their  capital;  and, 
crowning  all,  the  exhausting  fatigue  of  fighting  day  and 
night  for  six  consecutive  days,  pressing  the  enemy 
continually  forward, and  encountering  him  successfully 
in  five  Bevere  battles.  This  combination  of  depressing 
causes  had  a  very  marked  effect  upon  the  recuperative 
powers  of  our  wounded  men.  and  eases  of  profuse  sup- 
puration, with  pyemia,  erysipelas,  hospital  gangrene^ 
etc.,  filled  the  hospitals. 

A  certain  amount  of  hemorrhage  always  accompa- 
nies gunshot  wounds;  but,  owing  to  the  irregularity 
ami  the  asperities  of  the  sides  of  the  wound  favoring 
the  clotting  of  blood,  we  usually  find  that  the  external 
flow,  however  excessive  it  may  be  for  a  short  time, 
soon  ceases,  while  concealed  hemorrhage,  to  a  limited 
extent,  extravasates  blood  into  the  surrounding 
tissues.  When  the  divided  blood-vessels  are  so  closed 
that  the  blood-cells  can  no  longer  escape,  sorous  oozing 
still  goes  on.  increasing  the  in  tilt  ration.  These  are  the 
causes  of  the  rapid  swelling  which  follows  gunshot 
wounds.  When  arteries  of  considerable  size  are  not 
injured  in  the  passage  of  a  ball,  a  very  characteristic 

appearance  in  gunshot  wounds  is  the  dryness  of  such 
when  contrasted  with  wounds  produced  from  other 
causes.  This  dryness  depends  upon  the  laceration  of 
toe  tissues,  assisted  perhaps  by  an  excited  action  in  the 

divided  vessels,  from  the  application  of  the  heated  hall 

in  transit  — which,  all  bough  it  has  nol   a  sufficient  elcva- 

tion  of  temperature  to  sear  the  tissues,  would,  neverthe- 
less, stimulate  the  snnill  vessels  to  con  traction,  even  to 
the   closure  of  their  divided  mouths.     Those  arteries 

which  are  divided  hy  a  hall  in  rapid  motion  will  bleed 


PAIN    IN    GUNSHOT    WOUNDS.  165 

more  than  those  injured  by  a  slow  or  spent  ball,  and 
large  vessels,  when  injured,  will,  of  course,  bleed  more 
profusely  than  the  smaller  ones,  and  the  hemorrhage 
from  those  partially  divided  is  always  excessive. 

The  pain  which  accompanies  the  reception  of  gun- 
shot injuries  is  often  so  trivial,  that  the  attention 
of  the  wounded  is  only  called  to  the  fact  by  blood 
streaming  down  the  limb.  McLcod  mentions  the  case 
of  an  officer  who  had  both  of  his  legs  carried  away, 
and  experienced  so  little  pain  that  he  only  became 
aware  of  the  injury  which  he  had  received  when  he 
attempted  to  rise.  The  majority  liken  the  striking  of 
a  ball  to  a  smart  blow  with  a  supple  walking-cane,  or 
a  sensation  of  heat  through  the  part  struck  ;  while 
with  a  few  the  pain  is  very  severe,  and  simulates  the 
feeling  which  would  be  produced  by  running  a  red-hot 
wire  through  the  flesh. 

It  appears  that  every  minshot  wound  is  accompanied 
by  a  certain  amount  of  shock,  which  in  some  would 
be  scarcely  perceptible,  but  in  many  is  well  defined, 
and  in  serious  cases  of  wounds  very  persistent.  Im- 
mediately upon  the  receipt  of  injury,  the  features 
of  the  patient  may  indicate  alarm.  His  face  indicates 
anxiety  and  distress.  He  looks  pale,  with  colorless 
lips  ;  feels  cold,  trembles,  and  complains  of  feeling  taint, 
with  perhaps  sickness  of  stomach  and  vomiting.  His 
pulse  is  feeble  and  quick,  respiration  irregular,  and  in- 
terrupted with  sighs;  his  skin  cold  and  moist,  sometimes 
wet  with  a  clammy  perspiration  ;  the  features  seeming 
to  shrink  from  tie-  contraction  of  the  blood-vessels, 
which  are  comparatively  emptied  of  blood.  Whether 
this  general  shock  be  marked  or  not,  there  is  in  all 
gunshol   wounds,  immediately  alter  their  reception,  a 

lo<ai  shock  or  partial  paralysis  of  sensatjon — a  numb- 
which  is  nature's  preparation,  permitting  a  thor- 


166  NEB 

ough  examination  with  little  or  no  pain.  The  unusual 
quiet  of  a  hospital  1 1 » « *  night  following  a  battle  h 
been  repeatedly  noticed,  and  is  accounted  for  by  this 
nervous  shock.  When  this  condition  passes  off,  then 
reaction  brings  with  it  much  Buffering.  In  this  ner- 
vous shock,  with    the   suspension   of  activity  in  the 

circulatory  tin  id  ion,  lies  the  Safety  of  many  a  wounded 

.  er.  1 1  influence  is  immediately  felt  in  the  injured 
'tissues.  A.s  the  heart's  action  is  controlled  and  the 
pulse  very  feeble,  the  vessels  are  not  distended  with 
blood,  and  the  infiltration  and  engorgement  «>t  the  tis- 
sues  are  prevented.  When  nervous  depression  exists, 
luit  little  blood  escapes  from  the  injured  vessels;  and  as 
there  is  no  force  from  behind,  owing  to  the  diminished 
action  Of  the  heart,  to  drive  on  and  keep  in  motion  this 

blood,  its  clotting  is  favored.  Before  reaction  ens;, 
the  riot  ha-  had  time  to  form  and  to  solidity,  and  has 
become  bo  firmly  established  that  it  can  not  be  dis- 
placed. By  the  addition  of  a  fibrinous  secretion  from 
the  capillaries,  the  injured  vessels  remain  thoroughly 
and  permanently  plugged  up.  and  the  dangers  from 
immediate  hemorrhage  are  prevented.  Shock  may  ac- 
company a  very  Blight  injury,  ami  may  exhibit  itself 
in  the  most  courageous  and  intelligent,  so  that  it  can 
not  always   he    attributed     to   alarm.      <  >n     the    other 

band,  a  very  severe  wound  may  be  unaccompanied  by 
any  perceptible  agitation. 

The  duration  of  this  shock  i-  wvy  variable  —lasting 
hut  a  lew  minutes  in  most  instances,  and  passing  away 
without  medical  assistance;  in  other  cases  persisting, 
notwithstanding  the  internal  use  of  stimuli  and  ex- 
ternal application  of  warmth  combined  with  stimu- 
lating remedies. 

When  shock  exists  we  try  to  ascertain  the  cause, 
which  a  glance  at  the  position  of  the  wound  will  often 


IMMEDIATE  ATTENDANCE  IN  GUNSHOT  WOUNDS.      1G7 

give  us.  If  the  cause  appears  trivial,  the  statement  of 
the  fact,  with  a  few  cheering  words,  will  reas- 
sure the  wounded  man,  and  soon  restore  him  to  him- 
self. Whore  the  depression  is  deeper  and  connected 
with  a  serious  injury,  the  course  pursued  is  to  admin- 
ister a  dose  of  morphine  in  a  drink  of  brandy  and 
water.  If  conveniences  are  nt  hand,  it  would  be  ad- 
vantageous to  administer  the  toddy  hot.  The  patient 
Bhould  be,  at  the  same  time,  covered  with  several 
blankets  or  other  warm  clothing;  pulverized  mustard 
or  red  pepper  may  be  rubbed  upon  the  legs  and  arms, 
or  plasters  of  the  same  substances  extensively  applied 
upon  the  skin,  or  the  limbs  may  be  encircled  with 
bottles  of  hot  water.  The  return  of  warmth  to  the 
surface,  and  with  it  an  improvement  in  the  strength  of 
the  pulse,  is  an  indication  that  the  heart  will  soon 
have  force  enough  to  drive  blood  to  the  brain  and  all 
parts  of  the  body,  to  the  relief  of  the  patient  and  disap- 
pearance of  the  symptoms  of  shock. 

As  the  wounded  soldier  is  always  clamorous  of  hav- 
ing his  injuries  attended  to  as  early  as  possible,  and  as 
experience  teaches  that  all  wounds,  and,  above  all 
others,  gunshot  wounds,  are  benefited  by  immediate 
dressing,  they  should  be  attended  to  on  the  field 
of  battle.  Under  such  circumstances,  wounds  give 
less  trouble  to  the  surgeon,  less  pain  to  the  soldier,  and 
much  better  final  results  in  treatment.  All  hasty 
ags  or  examinations  are  to  be  deprecated,  and 
$  methodic  pursued.     The  indications  of  treat- 

ment, in  all  gunshot  wounds,  an — 1st.  To  control 
hemorrhage;  2d.  To  cleanse  the  wound  by  removing 
all  foreign  bodies;  and,  3d.  To  apply  such  dressings, 
and  pursue  such  i  rational  course  of  treatment,  as  will 
e.-t:iblish  rapid  cicatrisation. 

lb  morrhage,  which  product  a  such  terror  in  the  by- 


168  nKMunnnAOF. — now  OONTRAOflD. 

standera  an<l  anxiety  in  the  patient,  Bhould  never  un- 
nerve the  Burgeon,  who  requires  all  of  his  self]. 
Bion  and  surgical  tact  to  cope  successfully  with  this 
ebbing  away  of  life.  Fortunately,  in  gunshot  wounds 
serious  hemorrhage  is  of  rare  occurrence;  ami  when 
the  largest  arteries  arc  injured, as  a  rule  they  either 
eease  bleeding  spontaneously,  or  the  patient  di 
rapidly  that  art  is  of  little  avail,  [n  the  Crimean  war, 
researches  into  the  cause  of  death  upon  the  battle-field 
has  given  eighteen  per  cent,  of  the  deaths  to  primary 
hemorrhage  from  the  large  blood-vessels  of  the  trunk. 
If  the  case  is  not  injuriously  interfered  with,  the 
natural  haemostatics  will  often  control  the  bleeding. 
I  n  examining  the  table  of  ligation  of  arteries,  it  will  be 
seen  how  very  few  cases  are  reported  as  having  been 
operated  upon  for  primary  hemorrhage.  In  a  con- 
solidated table  of  all  the  ligations  performed  on  tire 
field,  and  reported  by  Burgoons  to  the  surgeon-gen- 
eral's office,  during  nearly  three  years  of  actual  war- 
fare, but  two  cases  of  primary  ligation  of  the  femoral 
artery  and  one  of  the  brachial  artery  are  noted.  The 
ragged  character  of  the  wound,  and  the  nervous  shook 
accompanying  the  injury,  or  brought  on  by  the  l< 
blood,  reacting  upon  the  circulatory  organs,  so  dimin- 
ish the  heart's  impulse  thai  it  drives  little  blood  to 
the  extremities,  which  favors  a  stagnation  of  blood  in 
the  wound.  In  those  cases  where  the  artery  is  Com- 
pletely Bevered,  the  formation  of  a  clot  plugs  up  the 
orifice  in  a  bleeding  vessel,  and  stops  any  further  loss 

ot   hlo.nl.      Where  a  large  artery  is  but   partially  divid- 
ed, the  Vessel  can  not  contract  and  retract,  thereby 
diminishing  its  canal,  as  is  the  case  when  the  \ 
is  completely  divided,  and    in    such    hemorrhage   i.s 
much  more  frequent  ly  fatal. 

This  spontaneous  arrest  of  hemorrhage  is  usually  per. 


ARREST    OF    HEMORRHAGE.  169 

manent ;  and,  if  the  ordinary  prophylactic  couq^  is 
pursued,  of  absolute  rest  and  quiet,  with  the  limb  ele- 
vated, no  return  shows  itself.  Should,  on  the  conti-ary, 
meddlesome  surgery  suggest  the  use  of  a  tourniquet, 
which  cuts  off  the  circulation,  and  especially  the  ve- 
nous return,  the  limb  soon  swells,  tissues  become  en- 
gorged, excessive  extravasation  in  the  wound  follows, 
and  a  train  is  laid  for  future  mischief.  The  field  tour- 
niquet, in  former  days,  was  so  much  in  vogue  that  it 
was  considered  indispensable  on  the  battle-field,  and 
was,  therefore,  carried  in  large  numbers,  so  as  to  be 
applied  to  every  limb  from  which  blood  was  trick- 
ling, or  from  which  hemorrhage  was  feared.  Now 
they  are  nearly  discarded  from  field  service,  and  recent 
experience,  based  upon  the  carelessness  with  which 
they  are  used,  recommends  their  abolition  from  the 
field,  as  doing  more  harm  than  good  to  the  wounded. 
I'nless  very  tightly  applied,  they  are  of  no  service,  as 
they  do  not  control  the  bleeding,  and  if  firmly  applied 
they  act  as  a  general  ligature  around  the  extremity, 
and  can  be  used  but  for  a  short  time  without  injury  to 
the  limb. 

lucent  writers  warn  surgeons  of  the  too  hasty  use 
of  haemostatics,  and  suggest  that  it  is  better  for  the 
wounded  t<>  bleed,  which  will  diminish  the  heart's  pro- 
pulsive force,  than  have  the  wounded  tissues  filled  with 
extravasated  blood. 

The  free  admission  of  air  to  the  wound  has  also  a 
decided  effect  in  hastening  the  clotting  of  blood,  in 
stimulating  the  open  mouths  of  divided  vessels  to  con- 
traction, and  thereby  in  controlling  bleeding.  In  fact, 
the  free  admission  of  air  to  a  wound  is  classed  among 
our  best  hemostatics.  Operating  surgeons  have  fre- 
quently noticed  that  when  flaps  are  brought  together 
immediately  after  so  operation,  annoying  hemorrhage 
o 


170  ARREST   OF    HEMORRHAGE. 

oc^^s  within  this  sac.  and,  by  its  accumulation, 
stretches  the  suturefl  and  makes  tense  the  flaps.  Tins 
distension  I »t-c-< > 1 1 1 i  1 1 ^r  oxcessive,  and  threatening  serious 
consequences,  the  sutures  are  divided,  the  flaps  opened, 
and  c-1' >ts  of  blood  removed,  when  the  bleeding  vessel 
will  often  so  immediately  close  that  it  can  noi  be 
found;  nor  will  it  again  bleed.  The  same  beneficial 
effects  are  found  in  gunshot  wounds. 

If  the  hemorrhage  be  free,  immediately  after  the 
receipt  of  injury,  the  best  mode  of  controlling  it  would 
be  the  application  of  a  ball  of  lint,  a  compress,  or 
sponge  over  the  wound,  secured  by  a  bandage,  which, 
in  closing  the  outer  orifice,  favors  the  formation  of  a 
clot.  If  the  hemorrhage  is  at  all  active,  as  from  some 
large  artery,  in  addition  to  the  compress  on  the  wound, 
the  entire  limb  should  be  carefully  enveloped  in  a 
bandage,  to  some  distance  above  the  injury,  so  that  the 
pressure  made  upon  the  soft  parts  would  diminish  the 
amount  of  circulating  fluid  in  the  limb,  and  prevent 
the  ingress  of  blood  into  the  tissues.  The  haemostatic 
properties  of  this  dressing  are  very  much  increased  by 
soaking  the  sponge,  or  compress  covering  the  wound, 

with  the  porchlorido  or  persulphate  of'ir which,  as 

a  powerful  astringent,  when  brought  in  contact  with 
fresh  blood,  will  immediately  form  a  clot.  Either  of 
t  hese  preparations  of  iron  poured  into  a  wound,  or  the 
injection  of  a  solution  of  the  perchloride  of  iron  into 
the  wound,  not  using  force  enough  to  infiltrate  the 
tissues,  is  an  excellent  method  of"establishing  a  solid 
clot  up  to  the  very  bleeding  mouth  <>f  the  injured 
vessel.  These  preparal  ions  of  iron  are  also  used  in  the 
form  of  powder,  and  are  equally  efficacious.  A  lump 
of  ice  placed  upon  the  compress  will  act  with  equal 
vigor.  A  sponge  or  compress,  tied  on  the  bleeding 
wound,  with  or  without  the  iron  styptic,  is  all  that  the 


ARREST   OF    HEMORRHAGE.  171 

surgeon    superintending    the    transportation    of  the 
wounded  is  expected  to  do. 

Unless  the  hemorrhage  is  very  violent,  threatening  im- 
mediate destruction  of  life  J  he  tourniquet  is  rarely  require,! . 
All  recent  writers  on  military  surgery  recommend  that 
field  tourniquets  be  dispensed  with,  as  they  are  gener- 
ally a  useless,  and  often,  when  carelessly  used,  a  dan- 
gerous instrument,  and  our  extensive  experience  has 
not  advancod  their  utility.     They  are  still  issued  in 
large  numbers,  and  called  for  by  army  surgeons  only 
because  they  are  upon  the  supply  table  for  field  ser- 
vice ;  but  very  few  of  them  are  ever  removed  from  the 
medical   store-chest,  where  they  remain  as  mementos 
of  a  former  practice.     .Surgeons  of  large  experience  on 
many  bloody  battle-fields  have  never  seen  it  necessary 
to  apply  them.     The  finger  pressure  of  an  intelligent 
assistant  is  better  than  any  tourniquet  ever  made,  and 
is   a    far   preferable    means   of  controlling  excessive 
hemorrhage,  which  (he  compress  and  bandage  may  fail 
to  check.     The  femoral  artery,  for  any  injury  to  its 
trunk  or  large  branches,  should  bo  compressed  in  the 
groin  where  it  runs  over  the  pubic  bone;  the  brachial, 
where  it  pulsates  against  the  head  of  the  humerus,  as 
at  this  point  its  course  is  nearly  subcutaneous.     When 
the  position  of  these  main  trunks  arc  shown  toany  in- 
telligent assistant,  and  he  is  made  to  recognize  the 
throbbing  of  the   artery,   he    will    have    no  difficulty 
in  keeping  the  vessel  compressed  during  the  transpor- 
tation.    Should  the  surgeon  be  doubtful  of  the  exact 
position  of  the  vessel  or  the  intelligence  of  his  assist- 
ant, the  finger  may  be  thrust  into  the  depths  of  the 
wound  and  be  applied  directly  to  the  seat  of  injury  in 
the  vessel,  thus  temporarily  checking,  and  if  sufficient- 
ly long  continue, i.  often  permanently  controlling,  the 
bleeding. 


172  EXAMINATION    OP    Woiv 

A-  soon  as  the  wounded  arrive  at  the  temporary 
resting-place  or  field  infirmary,  where  the  Burgeons 
are  assembled,  all  bandages  arc  romovod,  and  the 
wounds  carefully  examined.  A  glance  at  the  wound/ 
when  tin-  clothing  has  been  previously  inspected,  will 
often  tell,  when  there  an-  two  orifices  differing  in 
appearance  and  in  a  direct  line  with  each  other, 
whether  foreign  bodies  have  lodged  or  not.  As  the 
patient  is  now  taint  from  loss  of  blood  ami  from  ner- 
vous depression,  the  wound  not  yet  being  painful  or 
swollen,  the  surgeon,  using  his  finger — which  is  the  only 
admissible  />r<>hr.  on  such  occasion*  that  the  military  8Ufi> 
gcon  of  experience  recognizes — examines  with  it.  if  possi- 
ble, the  entire  extent  of  the  wound,  searching  tor 
foreign  bodies.  Where  the  orifice  is  too  small  to  admit 
the  index  finger,  the  little  finger  will  he  found  equally 
serviceable,  and  by  flattening  the  limb,  by  making 
pressure  upon  the  side  opposite  to  and  against  the 
finger,  a  much  greater  extent  of  the  wound  can  ho 
explored. 

This  examination  is  made  without  fear  of  reproduc- 
ing hemorrhage,  as   the  linger  can  not   displace  the 

dots  which  hold  firmly  to  the  openings  in  tin'  \ 
Every  surgeon  has  noticed  how  rudely  a  stump  might 
he  sponged,  and  what  force  it  requiroa  to  wipe  away 
clots  which  have  formed  over  the  far,'  of  a  smooth, 
incised,  open  wound.  The  adhesions  are  increased  a 
hundred  fold  by  the  irregularities  of  a  concealed  bullet 
track.  The  finger  finds  no  difficulty  in  entering  a  hole 
through  which  a  bullet  has  passed,  if  examined,  as 
every  wound  ought  to  be,  before  swelling  has  taken 
plaec. 

In  examining  fresh  wounds,  a  silver  probe  will  travel 
in    the   direction    given    to    it   by    the   surgeon;   and  .08 

most  persons  guide  the  probe  instead  of  allowing  the  probe 


PROBING    OF    WOUNDS.  173 

to  guide  them,  the  true  course  of  a  ball  can  only  be  de- 
termined by  it  with  great  difficulty.  It  is  but  recently 
that  I  saw  a  physician  of  experience,  in  seeking  the 
course  of  a.  ball  which  had  lodged  in  the  thigh, pass  the 
probe,  apparently  without  effort,  among  the  muscles 
quite  across  the  limb,  so  that,  the  bullet  wound  being 
on  the  outer  side  of  the  thigh,  the  end  of  the  probe 
could  be  felt  under  the  skin  on  its  inner  side.  When 
the  finger  was  introduced,  it  followed  the  track  of  the 
ball  at  a  very  oblique  course  from  the  one  which 
the  probe  had  taken.  This  example,  which  is  only 
one  of  the  many  of  frequent  occurrence,  is  sufficient  to 
show  why  military  surgeons  of  expei-ience  denounce 
the  silver  probe,  and  distinguish  by  its  use  the  tyro  in 
surgical  practice. 

In  those  cases  only  in  which,  from  the  small  size  of 
the  orifice  made  by  pistol  balls,  the  finger  can  not 
be  introduced,  is  a  large  bulbed  ball  probe,  a  female 
catheter,  or,  lastly,  an  ordinary  silver  probe,  used. 
Elastic  bougies  have  been  recommended  for  the  exami- 
nation of  extensive  wounds,  but  they  are  apt  to  bend 
should  they  meet  an  obstacle  or  irregularit}*  in  the 
track,  and  when  used  for  detecting  foreign  bodies  do 
not  convey  the  same  satisfactory  information  as  do 
metallic  instruments. 

The  wound  is  examined  from  both  sides,  with  the 
double  object  of  finding  foreign  bodies  which  may 
have  lodged,  and  seeing  the  proximity  of  the  course  of 
the  hall  to  the  main  arteries  of  the  limb.  It  is  a  mat- 
ter of  importance  to  determine  the  condition  of  large 
Vessels,  whether  they  be  injured  or  not,  by  examining 
the  degree  of  pulsation  which  they  possess,  as  such  an 
injury  would  necessitate  a  morecareful  after-treatment) 
in  order  to  prevent  secondary  hemorrhage. 

In  some  cases  the  finger  introduced  into  the  opening, 


174  PROBING    OP    WOUNDS. 

after  passing  through  the  skin  and  cellular  tissue,  finds 
no  further  passage.  This  sudden  arrest  of  the  finger 
would  indicate  either  that  the  ball  had  been  drawn  oul 
with  the  removal  <>t  the  clothing,  or  thai  the  deep  tis- 
muscles,  and  aponeuroses  have  changed  (heir  re- 
lations on  account  of  changes  in  tin-  position  of  the 
limb.  The  track  of  ilie  ball  will  not  be  discovered 
until  the  former  relations  of  the  parts  he  resumed,  by 
placing  the  limb  in  the  same  position  in  which  it  had 
received  the  injury,  when  the  entire  route  of  the  hall 
will  he  traced. 

The  inexperienced,  readily  deceived  by  the  little  re- 
sistance met  with  in  probing  recent  wounds,  mistaking 
muscular  interstices  for  the  trade  of  the  hall,  make 
several  false  passages  in  their  search  for  tin-  foreign 
body,  and  by  their  isolation  or  denudation  of  the  parte 
cause  inflammation  and  add  to  the  difficulties  of  further 
examination.  When  the  finger,  buried  in  the  wound, 
shows  that  it  is  continued  beyond  reach,  a  hall  probe 
or  silver  catheter,  introduced  carefully  and  without  force, 
will  often  reach  ami   detect  the  foreign  body. 

In  the  examination  of  gunshot  wounds,  to  detect  the 
presence  of  a  hall,  when,  by  the  use  of  a  silver  hall 
probe,  a  hard  foreign  body  is  discovered,  but  from  the 
depth  of  the  wound  and  the  little  play  of  the  bulb  of 
the  probe,  it  is  impossible  to  determine  whether  we 
are  feeling  an  exposed  portion  of  bone  or  cartilage, 
or  have  actually  found  the  foreign  body  which  we 
are  seeking,  we  can  at  once  solve  oar  doubts  and  es- 
tablish an  accurate  diagnosis  by  means  of  Nelaton's 
probe,  which  differs  from  the  ordinary  hall  probe  in 
having  an  unglazed  porcelain  bulb  at  its  extremity. 
When  this  bulb,  buried  in  the  depth  of  a  gunshot 
wound,  reaches  the  suspected  foreign  body,  it  is  only 
isary  to  rotate  it  a  few  times  against  the  hard 


PROBING   OF    WOUNDS.  175 

mass  and  then  withdraw  it;  when,  if  it  has  been 
rubbed  against  a  load  ball,  its  surface  will  be  blacked 
by  particles  of  the  metal,  which  discoloration  can 
be  produced  by  no  other  substance.  This  simple  in- 
strument is  a  triumph  of  surgical  ingenuity. 

Should  but  one  opening  exist,  and  the  clothing 
of  the  soldier  covering  the  wound  be  torn,  the  proba- 
bility is  thai  foreign  bodies  complicate  the  wound. 
When  two  openings  exist,  indicating  the  escape. of  a 
ball,  an  examination  should  still  be  made,  to  detect,  if 
possible, the  presence  offoreign  bodies,  such  as  portions 
of  clothing,  etc.  It  must  be  remembered  that  the  ball, 
as  a  hard  body,  can  usually  be  readily  recognized,  but 
that,  portions  of  wadding  or  clothing  may  be  easily 
mistaken  for  a  clot  of  blood  or  the  ragged  lining  of 
the  wound.  This  is  particularly  the  ease  when  they 
become  saturated  with  the  secretions.  Forewarned 
being  forearmed,  the  surgeon,  remembering  these  diffi- 
culties, will  examine  with  special  care  for  these  soft, 
foreign  complications.  When  found  they  should  be 
extracted,  as  their  presence  is  certain  to  establish  a 
high  degree  of  inflammatory  excitement,  with  profuse 
and  long  continued  suppuration. 

This  effect  was  well  shown  in  the  case  of  a  private 
of  the  Second  regiment  of  South  Carolina  volunteei'S, 
who,  during  the  attack  on  Fort  Sumter,  was  shot  by 
the  accidental  discharge  of  a  musket.  The  ball 
entered  the  ch est  at  the  anterior  told  of  the  armpit, 
fractured  the  clavicle,  and. after  a  course  of  nearly  six 
inches,  was  slopped  by  the  tough  skin  over  the  poste- 
rior portion  oi  the  shoulder.  The  ball  was  readily  de- 
tected  by  the  regimental  surgeon,  and.  by  an  incision 
through  the  skin,  was  easily  removed.  Inflammation 
of  a  high  grade  having  supervened  upon  the  accident, 
he  was  sent  to  the  general  hospital  one  week  after  the 


1  T « V  PROBING    OF    WOURDB. 

injury  was  received — at  which  time  be  was  Losing  from 

three  to  four  ounces  of  pus  daily.  On  the  day  after 
his  admission,  in  examining  the  wound,  I  detected  in 
the  shoulder  wound  sum*'  substance  resembling  a 
slough,  and,  upon  extracting  it,  found  a  mass  oi  coal 
pad,  over  two  inches  long  and  as  thick  as  the  finger, 
which  tent-like  mass  bad  been  driven  into  the  wound, 
and  having  been  entangled  by  the  irregular  tissues 
through  which  it  had  been  driven,  had  been  left 
behind  by  the  ball.  An  examination  of  his  clothing, 
made  for  the  first  time,  showed  a  deficiency  in  the 
lining  of  his  coat,  from  which  this  mass  had  been  torn. 
The  removal  of  this  irritant  diminished  the  discharge 
immediately,  so  that,  in  the  succeeding  twenty-four 
hours,  the  discharge  diminished  to  one-sixth  its  former 
quantity,  and  in  four  days  was  hardly  sufficient  to  soil 
the  dressing. 

The  history  of  the  case  is  of  much  importance  in  exam- 
ining gunshot  icounds,  as  often  the  course  of  the  ball 
can  not  be  discovered  without  it.  What  surgeon,  how- 
ever great  his  experience,  Seeing  a  wound  made  in  the 
arm  by  a  ball,  would  think  of  looking  in  tin-  opposite 
thigh  for  its  place  of  lodgement,  did  he  not  learn  that 
the  injury  was  received  from  above,  while  mounting  a 
scaling-ladder,  with  arms  raised  above  the  patient's 
head  ?  The  ball  entering  the  back  of  the  arm  near  the 
elbow,  had  passed  down  the  arm  under  the  shoulder- 
blade,  across  the  loin,  and,  traversing  the  buttock,  had 
lodged  under  the  skin  of  the  outer  part  of  the  opposite 
thigh,  where  it  was  found  and  removed. 

A  ease  in  point  was  that  of  Private  K\,  7th  S.  C.  V. 
regiment,  who  was  shot  in  the  neck  at  the  Battle  of 
.Malvern  Hill,  June  oO,  18C»2.  J  lis  wound  was  consid- 
ered trivial,  and  a  furlough  of  thirty  days  granted, 
lie  came  under  my  observation  a  lew  days  after  the  re- 


PROBING    OP    WOUNDS.  177 

ccption  of  the  injury  with  the  neck  very  much  swollen, 
and  a  severe  pharyngitis,  with  tonsilar  enlargement 
seriously  obstructing  respiration  and  deglutition. 
The  swelling  on  the  back  of  the  neck  caused  him  to 
cany  the  chin  touching  the  sternum.  A  large  orifice, 
from  apparently  a  minio  ball,  existed  on  the  left 
side  of  the  neck,  one  and  a  half  inches  from,  and  on  a 
level  with,  the  spine  of  the  sixth  cervical  vertebra). 
When  the  wound  was  probed  it  was  found  to  traverse 
the  neck,  running  over  without  fracturing  the  spine  of 
the  cervical  vertebra?,  and  then  to  change  its  course 
obliquely  downward  and  outward.  Profuse  suppura- 
tion soon  came  on,  the  pus  burrowing  under  the  right 
scapula,  caused,  as  was  supposed,  by  some  foreign  body, 
probably  the  ball,  as  there  was  but  one  orifice  to  the 
wound.  After  some  days  of  treatment  an  opening 
was  made  on  the  right  side  of  the  back,  above  the  upper 
edge  of  the  scapula,  and  the  neighborhood  thoroughly 
explored.  The  subscapular  region  was  found  under- 
mined and  the  neck  of  the  scapula  fractured,  but 
no  foreign  body  could  be  discovered  after  the  most 
careful  search.  Suppuration  continued  profuse  for 
weeks,  reducing  the  patient  to  the  very  last  extremi- 
ty, with  extreme  emaciation.*  lie  finall}'  rallied, 
thanks  to  a  good  constitution  and  good  nursing,  and 
was  at  last  sent  home  convalescent.  In  time  an  ab- 
scess formed  in  the  immediate  vicinity  of  the  elbow 
joint,  and  a  large  ininie  ball  was  extracted  from  this 
situation.  When  he  received  his  wound  he  was  load- 
ing his  rifle,  and  was  in  the  act  of  biting  the  cartridge, 
with  arm  raised  and  face  depressed.  With  this  history 
of  the  ease,  the  position  of  the  ball  could  be  readily 
accounted  for. 

Knowing  the  direction  from  whence  the  ball  came, 
and  the  position  in  which  the  soldier  was  placed,  you 


178  PROBING    OF    WOUNDS. 

will  auspecl  the  course  whioh  the  ball  would  mosl 
probabjy  take;  and  your  examinations  in  that  direc- 
tion will  i k>!  only  save  much  time,  but  save  the  patient 
much  Buffering  and  annoyance. 

The  probing  of  wounds  to  find  incarcerated  kills 
should  be  accompanied  by  a  thorough  and  extensive 
externa]  examination  of  the  surface,  by  running  the 
hand  over  the  limb  <>r  trunk,  pressing  both  lightly  and 
firmly,  in  order  to  detect  any  abnormal  induration. 
The  position  of  balls  is  often  discovered  by  palpation 
alone,  and  in  certain  cases  large  masses  of  iron  have 
remained  embedded  in  the  soft  parts  unsuspected, 
McLeod  recorded  a  case  from  the  Scutari  hospitals,  in 
which  a  piece  of  shell,  weighing  three  pounds,  bad 
buried  itself  in  a  soldier's  leg,  making  so  small  an 
opening  that  its  presence  was  overlooked  for  three 
months.  Larrey  reports  a  case  in  which  a  five-pound 
hall  buried  itself  in  the  thigh  ;  Begin  a  case  of  a  nine- 
pound  ball;  and  Hennen  one  in  which  a  twelve-pound 
shot  remained  in  the  thigh,  and  was  only  discovered 
alter  death.  Ae  round  shot  are  rarely  used  in  modern 
warfare,  no  such  case  has  yet  been  reported  from  our 
armies.  For  this  examination  the  entire  limb  must 
be  exposed,  and,  in  injuries  of  the  trunk,  the  patient 
should  be  stripped.  Valuable  assistance  is  often  ob- 
tained from  the  patient  himself,  who  suggests,  from 
increased  sensitiveness  over  a  particular  point,  where 
the  ball  might  be  found,  or  he  may  have  detected  the 
ball  by  the  sudden  formation  of  a  tumor  where  no  hard 
swelling  had  before  existed. 

Often  the  play  of  a  muscle  will  shut  oil' the  track  of 
the  ball.  The  relations  of  the  soft  parts  vary  with 
vvrry  position  of  the  limb,  and  a  passage  made  when 
a  limb  was  ilexed  could  not  be  followed  when  the 
same  limb  is  extended.     Hence  the  necessity  of  plac- 


REMOVAL    OF    FOREIGN    BODIES.  179 

r 

ing  the  limb  in  the  same  position  in  which  it  -was 
when  the  injury  was  received. 

The  wound  having  been  carefully  examined  by  the 
finger  within  and  careful  manipulations  without,  and 
the  foreign  body  detected,  it  should  be  at  once  re- 
moved. This  rule  may  nearly  be  considered  absolute, 
as  all  military  surgeons  place  great  weight  upon  its 
accomplishment.  The  question  is  not  so  much  wheth- 
er balls  can  remain  innocuous  in  the  flesh,  but  do  they  f 
Those  who  have  had  experience  in  the  treatment  of 
gunshot  wounds  know  how  excessive  is  the  irritability 
caused  by  the  presence  of  a  ball  in  a  wound;  how 
restless  and  irritable  the  patient  is  until  it  is  removed  ; 
how  profuse  the  suppuration  and  prolonged  the  period 
of  treatment  in  those  cases  in  whidh  it  has  been  left ; 
and  how  frequently  the  after-consequences  aro  so 
distressing,  the  pain  so  permanent,  and  discharge  so 
constant,  as  to  demand  future  interference,  or  make 
life  a  burden.  If  such  be  the  case  with  a  ball,  how 
much  more  urgently  is  the  extraction  of  other  foreign 
bodies  indicated,  especially  fragments  of  shell,  por- 
tions of  clothing,  detached  pieces  of  bone,  etc.  ?  It  is 
only  by  carrying  out  this  most  urgent  indication 
in  the  commencement  of  the  treatment  that  a  number 
of  consecutive  dangers,  such  as  pain,  inflammation,  sup- 
puration, gangrene,  amputations,  and  even  death,  can 
be  avoided. 

Balls  may.  in  time,  become  encysted  ;  but  even  when 
such  occurs  their  presence,  in  after  years,  may  set  up 
inflammation,  which  will  mat  together  and  bind  dowti 
important  parts,  whose  usefulness  depends  upon  frees 
doin  of  motion.  Repeated  abscesses  may  form,  press- 
ure upon  bones  may  give  rise  to  ulceration  and  a 
tedious  exfoliation,  blood-vessels  may  ulcerate,  nerves 
be  painfully  compressed,  and  life   rendered   miserable, 


180  DANQBR    01    INCARCERATED    BALLS. 

if  not  Jeoparded.  Notwithstanding  all  that  lias  boon 
written  upon  the  innocuous  character  of  balls  embed- 
ded in  the  flesh, for  every  instance  in  which  they  have 
thus  remained,  without  giving  tr  >uble,  one  hundred 
(•an  be  exhibited  Bhowing  the  great  danger  of  foreign 
bodies  in  the  living  tissues.  Baron  Larrey's  experi- 
ence showed  that,  as  a  rule,  amputations  are  eventu< 
ally  necessary,  after  years  of  suffering,  in  those  cases 
in  which  halls  have  been  left  embedded  in  boneB. 
[These  remarks  are  equally  applicable  to  all  foreign 
bodies,  including  spicube  of  bone. 

In  McLeod'fl  Surgery  of  the  Crimea,  the  report  of 
M.  Hutin,  chief  surgeon  of  the  Hotel  des  Invalides,  is 
given,  which  is  a  Btr iking  commentary  in  favor  of  the 
removal  of  all  foreign  bodies,  lie  reports  that,  of 
four  thousand  cases  examined  by  him,  in  which  balls 
bad  remained  embedded,  ou\y  twelve  men  suffered  no 
inconvenience;  and  the  wounds  of  two  hundred  con- 
tinued to  open  and  close  until  the  foreign  body  was 
extracted. 

The  experience  of  the  various  hospital  boards 
throughout  the  Confederacy  for  the  examination  of 
Wounded  soldiers  on  furlough,  will  attest  the  impor- 
tance of  M.  Hutin's  remarks.  Very  rarely  is  a  sol- 
dier found  returning  to  his  regiment  with  a  hall  1111- 
extracted,  and  in  those  cases  in  which  the  position  of 
the  foreign  body  escapes  the  careful  examination  of 
the  surgical  stall',  painful  and  often  contracted  limbs 
are  uniformly  met  with,  rendering  the  patient  totally 
unlit   for  service. 

When  no  doubt  exists  that  a  foreign  body  compli- 
cates the  wound,  the  Burgeon  should  neglect  no  pre- 
caution to  discover  it.  As  a  general  rule,  he  will  find 
the  examination  facilitated  by  exposing  the  entire 
limb. 


EXTRACTION    OF    BALLS.  181 

It'  the  ball  be  felt  loose  in  the  soft  parts,  a  bullet 
forceps  can  be  made  to  seize  it;  and  it  can  be  extract- 
ed without  difficulty,  provided  the  disengaged  hand  of 
the  surgeon  support  the  limb  on  the  opposite  side  to  th<tt  at 
which  the  forceps  is  introduced;  otherwise,  the  ball  glides 
in  front  of  the  forceps  and  can  not  be  seized.  The  or- 
dinary bullet  forceps,  simulating  the  dressing  forceps 
of  the  pocket-case,  was  the  instrument  preferred  by 
Larrey,  and  is  still  in  general  use.  Man}-  changes 
have  been  made  in  these,  without  advancing,  to  any 
extent,  the  merits  of'  the  instrument.  An  excellent 
bullet  forceps,  which  is  the  one  now  issued  in  the  Con- 
federate  service,  terminates  with  a  sharp  prong  on 
cither  blade,  at  right  angles  to  the  blade,  SO  that,  when 
closed,  the  points  are  protected  by  the  blades.  These 
ad  as  an  axis  upon  which  the  ball  may  be  rolled  out 
of  the  wound,  instead  of  being  drawn  out,  as  with  the 
dressing  forceps. 

In  my  own  experience,  I  havo  found  an  ordinary 
dissecting  forceps,  with  toothed  extremity,  such  as  is 
met  with  in  all  recent  pocket-cases,  the  most  conven- 
ient instrument  for  extracting  balls.  The  teeth,  em- 
bedding themselves  in  the  lead,  allow  of  firm  traction 
without  fear  of  the  instrument,  slipping,  which  is  so 
constantly  the  ease  when  the  common  bullet  forceps 
is  used.  In  removing  a  flattened  ball,  especially  a 
mashed  minie  ball,  a  good  deal  of  force  is  often  re- 
quired to  disengage  and  extract  the  irregular  mass 
from  its  bed  in  the  soft  parts.  The  long,  ordinary 
bullet  forceps  is  an  unnecessarily  clumsy  instrument) 
made  apparently  with  the  belief  that  the  ball  will,  in 
every  instance,  be  sought  for  through  a  long  track  of 
Several  inches,  while  rarely  is  this  the  case.  The  hall 
i>  usually  found  near  the  surface,  and  can  he  readily 
removed  by  •■'  Bhorl  toothed  forceps,  which  is  much 
more  con\  unicntlv  handled 


182  EXTRACTION    OF    BALLS. 

Should  the  site  of  the  foreign  bod}^  be  not  at  once 
evident  after  the  examination  of  the  wound,  the  limb 
should  he  carefully   manipulated   for   some   distance 

from  the  wound.  As  the  objeel  of  the  examination  is 
to  detect  abnormal  projections,  the  slightest  elevation 
should  attract  attention.  When  no  projection  is  visi- 
ble, palpation  may  detect  a  hard  body  at  a  great 
depth  in  the  tissues.  The  hand  should,  at  first,  be 
run  lightly  over  the  surface,  as  light  pressure  would 
expose  the  indurated  spot,  the  site  of  a  ball,  when 
well  defined  pressure  would  move  the  object,  push  the 
ball  back  into  its  track,  and  cause  its  disappearance: 
If  the  tissues  are  soft,  the  foreign  body  can  be  seized 
between  the  fingers.  If  this  be  impossible,  palpation 
over  the  region,  as  for  detecting  fluctuation,  will  dis- 
cover the  hard,  resisting,  circumscribed  body.  Expe- 
rience soon  makes  perfect  in  this  kind  of  research,  and 
mistakes  are  rarely  made. 

In  cases  of  long  standing,  when  in  doubt  whether  an 
induration  be  a  ball  or  a  persistent  deposit  from  pre- 
viously existing  inflammation,  an  enlarged  lymphatic 
gland,  or  a  cartilaginous  formation  from  an  injured 
and  excited  periosteum,  I  have  found  valuable  aid  to 
diagnosis  from  the  use  of  a  fine  cutting  needle,  such 
as  is  used  in  couching  or  breaking  up  the  lens  in  cases 
of  cataract.  This  very  small  sharp  instrument  can  be 
used  upon  any  portion  of  the  body,  leaving  no  mark. 
It  gives  little  or  no  pain  in  transfixing  the  tissues,  and 
the  sensation  imparted  by  the  point  of  the  needle  em- 
bedding itself  in  lead  is  so  peculiar  that  a  surgeon,, 
with  experience  in  its  use,  can  not  be  mistaken  in  the 
diagnosis  of  an  induration  where  the  presence  of  a  ball 
is  suspected.  Should  a  ball  have  traversed  a  limb,  as 
it  often  docs,  and  its  escape  be  resisted  by  the  tough, 
elastic  skin  which  very  often  successfully  inpedes  (lie 
further  progress  of  the  ball,  it  should  be  removed  by 


EXTRACTION    OF    BALLS.  183 

making  an  incision  over  its  position,  and  not  be  BOUght 
for,  and  drawn  through,  tin' entire  length  of  the  track 
which  it  had  traversed. 

In  removing  subcutaneous  foreign  bodies,  do  not  cut. 
down  directly  upon  them,  as  it  will  destroy  the  edge 
of  the  knife — a  sad  accident  in  field  practice,  where  no 
conveniences  exist  lor  putting  instruments  in  order. 
8teadv  the  skin  over  the  supposed  site  by  fixi&g  the 
prominence  in  situ  between  the  thumb  and  index 
finger  of  the  left  hand.  A  sharp-pointed  straight  bis- 
toury held  obliquely,  the  edge  turned  toward  the 
operator,  is  then  thrust  obliquely  through  the  skin  and 
cellular  tissue  until  it  strikes  the  foreign  body,  when 
the  handle  of  the  knife  should  hi'  brought  over  toward 
the  operator,  thus  describing  a  segment  of  a  circle,  and 
making  a  sufficient  opening  in  the  skin  to  allow  of  the 
ready  escape  of  the  ball. 

.  If  the  ball  is  located  in  the  vicinity  of  import  ant 
blood-vessels  or  nerves,  and  there  is  fear  of  injuring 
important  structures  by  a  bold  thrust,  then  the  inci- 
sion for  its  extraction  must  be  made  with  more  care  by 
a  gradual  dissection  from  without,  dividing  the  tissues 
layer  by  layer. 

When  a  hall  is  firmly  embedded  in  bone,  it  can  be  re- 
moved by  boring  into  it  with  a  gimlet,  which  holds  it 
securel}-,  and  permits  sufficient  force  being  used  for 
dislodging  it,  or  it  may  be  cutout  by  using  a  trephine 
or  gouge.  The  latter  instrument  J  have  found  par- 
ticularly useful  in  opening  a  passage  through  bone,  so 
a-  to  permit  the  ready  removal  of  an  impacted  ball. 

After  exposing  a  point  of  the  foreign  body,  make  the 
incision  to  one  side,  or  pass  in  a  grooved  director  and 
cut  outward,  when  there  will  be  no  fear  of  doing  harm 
to  the  catting  edge  of  the  knife. 

Biiudens,  in  noting  the  difficult}'  of  extracting  these 


lvl  EXTRACTION    OF    BALLS. 

subcutaneous  Kails,  ascribes  it  i<»  a  layer  of  cellular  i  la- 
buo  which  lias  been  driven  in  front  of  the  ball,  and 
which  firmly  and  completely  caps  it.  It  is  thin 
enough  to  be  nearly  diaphanous,  and  yel  tough  enough 

to  clasp  and  hold  firmly  the  Indict.  This  condensed  cel- 
lular  tissue  musi  be  completely  divided.  My  own  ex- 
periencc  corroborates  thai  of  Guthrie,  who  says  that 
the  diilicultics  of  extraction  arc  increased  by  tho  Bur- 
geon when  fearful  of  making  a  tree  incision. 
in  extracted  with  the  least  pain  <m<l  with  great  rapidity  by 
making  </  bold  incision.  This  course  marks  the  differ- 
ence bet  ween  civil  and  military  surgeons  ;  half  an  inch 
added  to  the  incision  does  not  increase  its  dangers,  and 
expedites  materially  the  extraction.  Be  quite  sure, 
however,  that  yon  are  cutting  upon  a  ball  and  not 
upon  some  bony  prominence,  which  comparison  with 
the  opposite  limb  should  warn  you  from.  It  is  sulli- 
cicnt  to  mention  that  such  mistakes  have  happened  to 
military  Burgeons. 

By  foreign  bodies  we  mean  halls,  piecos  of  clothing, 
Hjiicuhc  of  hone  which  have  Keen  broken  off  and  are 
in  the  wound,  and  any  articles  about  the  person 
which  may  have  boen  driven  before  the  ball.  Those 
should  all  bo  removed  immediately  after  the  injury 
has  been  received,  and  before  swelling  or  infiltration 
fenders    the    task   difficult.      When    done   early,   the 

wound  will  he  found  sufficiently  largo  to  allow  of  easy 
extraction    without    dilating.       It     is    only    when    this 

early  a  Mention  is  neglected,  and  the  wound  has  closed 
by  inflammatory  effusions,  that  the  removal  is  painful 

and  difficult,  requiring,  in  some  instances,  the  use  of 
the  knife  to  enlarge    the   passage.       When    a  hall  alone 

complicates  a  wound,  if  it  he  nol  readily  found  after  a 
careful  and  intelligent  search,  rather  than  continue 
the  examination  from  day  to  day,  which  can  only  be 


EXTRACTION    OF    BALLS.  1S5 

prejudicial  to  the  cage  from  the  irritation  and  inflam- 
mation which  will  be  excited,  it  would  save  the  sur- 
geon much  anxiety  and  the  patient  much  annoyance 
if  the  ball  or  other  foreign  body  be  left  until  suppura- 
tion be  well  established.  Then  it  will  gradually  expose 
its  situation,  and  can  be  much  more  readily  removed 
than  during  the  height  of  reaction,  when  the  parts  are 
very  much  swollen  and  very  painful.  The  surgeon 
will  assist  nature  in  the  expulsion  as  soon  as  the  swell- 
ing baa  subsided  to  such  an  extent  that  the  finger  or 
the  forceps  can  again  be  introduced  into  the  wound. 

The  dilation  of  gunshot  wounds,  which  was  formerly 
the  constant  rule  of  practice,  is  now  altogether  reject- 
ed from  military  surgery,  unless  it  be  for  the  special 
purpose  of  ligating  a  bleeding  artery,  or  extracting 
foreign  bodies,  including  spicuhe,  which  could  not  be 
otherwise  readily  removed  without  injury  to  the  soft 
pa  lis.  This  old  medical  dogma  was  based  neither 
upon  experience  nor  observation,  and  is  now  very 
properly  considered  useless,  injurious,  and  barbarous. 

It  often  happens  that,  after  repeated  examinations, 
the  site  of  the  ball  can  not  be  fixed,  although  we  may 
feel  assured  that  it  still  remains  embedded  somewhere 
in  the  tissues.  Unless  serious  symptoms  exist,  as  se- 
vere and  constant  pain  indicating  pressure  upon  an 
important  nerve  and  leading  us  to  suspect  its  position, 
we  are  not  justified  in  cutting  down  at  random  to  look 
for  a  ball.  Unless  we  can  locate  with  some  certainty 
the  foreign  body,  it  is  a  good  rule  not  to  attempt  its 
search.      Tentative  incisions  usually  fail  of  their 

hould  not  be  made.  There  i>  no  excuse  lor  grop- 
ing about  blindly,  hoping  to  stumble  upon  a  hall  which 
is  hid  away  in  the  tissues.      Unless  we  can  feel  the  ball, 

we  niu-1   have  \>vy  strong  iv;i >   tor   believing  it  lo- 

:  in  any  particular  situation  before  resort  is  made 
I 


180  HBMORaHAQK — HOW    CO.NTHOLI.BD. 

to  the  knife.  Saving  found  a  ball,  it  is  equally  our" 
duty  to  remdve  it.  however  important  the  parte  anions 
whirli  it  is  located — as  its  presence,  if  left  in  the  living 
•  b,  always  entails  more  Bertous  trouble  than  the 
dangers  arising  from  the  operation  required  for  its  re- 
moval. At  times  su<h  operations  require  all  the  -kill 
of  adepts  in  surgery  toaocomplish  Bafely  the  object; 
hut  this  does  not  affect  the  established  rulo:  when  a 
/-.///  can  not  be  locaU </,  nt  m  r  opt  rati  for  its  r<  moval  unh  bs 
forced  by  the  presence  of  serious  symptoms,  which  map 
tin-mien  the  life  of  the  patient.  Where  a  ball  has,  on  the 
contrary,  been  found,  always  extract  it. 

The  above  rules  apply  chiofly  t<>  gunshot  wounds  of 
the  extremities ;  those  of  the  trunk  and  head  offer  so 
many  exceptions  to  the  above,  and  require,  in  a  meas- 
ure, Bnch  Bpecial  treatment,  that  the  course  to  be  pur- 
sued in  such  wounds,  complicated  with  foreign  bodies, 
will   he  specially  dealt  with  in  discussing  special   inju- 

We  have  already  Btated  that  fatal  hemorrhage, from 
tho  large  vessels  of  the  extremities,  does  not  often 
OCCUr  On  the  battle-fieldj   and  that    when  such  arteries 

are  wounded,  the  hemorrhage  is  either  so  immediately 
i'atal  that  no  assistance  can  he  rendered,  or  it  ceases 
spontaneously.     The  nervous  depression  so  common 

to  seriOUS  gnnshot  wounds,  with  its  tendency  to  -yn- 
cope,  and  its  control  over  the  circulatory  organs, 
check-  tie-  impulse  and  supply  of  blood  through  the 
injured  vessel,  and  promotes  the  formation  of  clots. 
Instances  are  reported  in  winch  openings  in  arteries 
have  l»e. -ii  temporarily  closed  by  foreign  bodies,  and  in 

Buch  oases  hemorrhage  had  recurred  when  these  had 
been  extracted.     Cases  are  often   met  with  in  which 

tin-  largest  arteries    had  heen  wounded,  and   in  which 

bleeding  ceased  spontaneously. 


HEMORRHAGE — HOW   CONTROLLED.  187 

When  hemorrhage  ia  not  actually  going  on,  or  the 
amount  of  blood  lost  has  not  been  .Been,  the  only 
means  of  detecting  the  injury  of  the  large  arteries  of  a 
limb  would  be  in  examining  carefully  the  strength  of 
pulsation  in  the  vessel  beyond  the  point  of  injury. 
A  diminution  of  its  force  when  compared  to  that  of 
the  corresponding  vessel  in  the  opposite  limb,  and 
especially  an  absence  of  pulsation,  shows  conclusively 
Bome  hindrance  to  the  circulation.  The  presence  of 
the  pulse  is,  of  course,  no  indication  that  injury  has  no! 
been  received. 

Although  from  the  course  of  the  ball  and  the  flow  of 
blood  wo  know  that  the  main  vessel  of  the  limb  has 
born  injured,  if  the  bleeding  has  ceased  spontaneously, 
or  by  the  pressure  of  the  sponge  or  compress  which 
was  tied  over  the  wound,  the  artery  should  not  be  in- 
terfered with.  7n  by  far  the  majority  of  cases,  if  proper 
precautions  be  taken,  there  will  be  no  recurrence  of  the 
hemorrhage.  The  patient  should  bo  kept  perfectly 
quiet,  free  from  all  causes  of  excitement,  at  perfect 
rest,  and,  to  ensure  that  the  limb  shall  not  be  moved, 
a  bandage  should  be  carefully  applied  from  the  ex- 
tremity of  the  limb  upward,  and  a  long  splint  secured. 
The  flannel  bandage  being  the  most  elastic,  is  the 
best  material  for  such  methodical  pressure  and  sup- 
port. Elevation  of  the  limb  will  add  much  to  the  effi- 
cacy of  the  preventive  treatment.  The  accumulated 
experience  of  field  surgeons  through  all  the  campaigns 
of  this  revolution,  and  their  condensed  reports  of  sur- 
gery on  the  battle-field,  will  show  how  rarely   is  it 

sary  to  ligato  large  vessels  injured  by  the  pa 
of  halls,  and  how  successfully  nature  controls  perma- 
nently tin-  hemorrhage  from  large  artei 

The  ligation  of  an  artery,  which  is  the  only  sure  pre- 
caution again>1  the  return  of  hemorrhage,  is  not  only 


188  HEMORRHAGE — !lnW    CONTROLLED 

a  difficult  operati  >n,  requiring  much  skill  for  its 
cessful  performance.  l>ut   when    necessary  to  control 
the   bleeding  from  a  recent  wound,  becomes  a  very 
dangerous  one  to  the  safety  of  the  limb  or  lite  of  the 
individual     In  casee  of  disease,  nature,  always  on  the 

has  enlarged  oontiguoas  blood-vessels,  which  are 
ready  to  assume  all  the  functions  of  the  one  requiring 
obliteration.  In  a  wound  in  a  healthy  person  no  such 
preparation  lias  been  made;  and  in  cutting  off  the 
main  supply  of  blood  through  a  limb,  it  becomes  a 
\<ry  serious  question,  often  answered  by  the  1"--  of 
the.  limb,  and  even  life,  whether  the  circulation  will  bo 

ablished  in  time  to  save  the  member  from  morti- 
fying. When  a  ligature  is  placed  upon  the  main 
artery  of  a  limb  for  disease,  previous  developments  in 
the  collateral  circulation  have  been  made  to  such  an 
extent  that  the  extremity  may  not  even  lose  tempera- 
ture after  the  ligation,  and  as  there  is  no  diminution 
of  the  nutrient  supply  there  is  no  fear  of  mortification. 
If  placed  on  a  healthy  vessel  for  an  injury,  the  limb  at 
oine  becomes  pale  and  cold,  requiring  the  application 
of  artificial  warmth  and  enveloping  in  flannels  to  sup- 
port life  in  it  until  the  circulation  be  re-established, 
when  the  limb  becomes  actually  warmer  than  its 
colleague,  because  the  supply  of  arterial  blood  is  uow 
disseminated  in  vessols  much  nearer  to  the  surface, 
while  before  its  chief  channel  was  deeply  embedded  in 
i  he  i  issues. 

The    rapidity  of  this   collateral   development  in    the 

limit  is  well  exhibited  in  primary  and  secondary  am- 
putations.     When  a  thigh  is  amputated  in  a  healthy 

portion,  xevy  seldom  are  there  more  than  three  01'  four 

Ligatures  required   to  stop  all  oozing  and  lender  the 
stump  quite  dry.     [f  the  amputation  be  necessary  :it 

ime  point  four  or  live  days  after  an  injury  to  the 


LIGATE    BOTH    BLEEDING    ORIFICES.  189 

main  vessel  has  been  received,  the  number  is  greatly 
increased;  as  many  as  twenty-eight  arteries  having 
been  Ligated  by  Langenbeck  after  amputating  a  thigh 
under  similar  circumstances, 

Should  active  hemorrhage  continue,  and  show  no 
disposition  to  cease,  or  the  quantity  of  blood  flowing 
from  the  wound  indicate  speedy  death  unless  the  hem- 
orrhage be  slopped,  the  wound  should  be  dilated,  the 
bleeding  mouths  of  the  artery  found,  and  a  ligature 
applied  both  above  and  below  the  injury.  This  has  be- 
come the  established  practice,  and  the  only  safe  one, 
taking  its  place  among  the  aphorisms  of  surgery.  The 
universal  adoption  of  this  practice  is  not  only  based 
upon  experience  and  observation,  but  could  be  deter- 
mined a  priori  from  the  physiology  and  anatomical  dis- 
tribution of  arteries. 

All  surgeons  are  familiar  with  the  anastomosis  or 
collateral  circulation  in  blood-vessels.  When  the  cur- 
rent of  blood,  flowing  through  a  main  vessel,  is  stopped 
at  any  one  point,  it  will  soon  find  its  way,  by  retrac- 
ing its  steps  through  man}-  circuitous  routes,  until  it 
comes  in  from  below,  and  thus  back  to  the  very  point 
at  which  its  direct  course  had  been  checked.  When 
an  artery  is  divided,  it  it  well  known  that,  owing  to  its 
muscular  and  elastic  structure,  that  portion  above  the 
wound  at  once  contracts  and  retracts,  so  that  the  tube, 
which  was  before  cylindrical,  now  resembles,  in  form, 
a  claret  bottle  with  a  much  constricted  neck  at  the 
point  wounded.  A  clot  of  blood  soon  forms  in  this 
mouth  and  neck-,  and  the  further  escape  of  blood 
through  lliis  opening  is  intercepted.  In  the  lower 
port  ion  of  the  divided  vessel  similar  changes  are  going 

on,  bui  not  to  go  great  an  extent.  The  contraction 
(owing  to  the  severing  of  the  nerves  which  run  upon 
and  between  the  coats  of  the  vessel,  and  which  give 


L1GATE    BOTH    BLEEDING    ORIFICES. 

tone  to  the  arterial  walls)  is  only  partial,  the  walls  be- 
ing  to  a  certain  extent  paralyzed,  and  so  little  blood 
remains  in  the  tube  tbat  a  very  small  and  indifferent 
clot  is  formed. 

When  the  upper  portion  of  the  artery  is  firmly 
closed,  preventing  all  egress  to  blood,  the  lower  por- 
tion remains  patulous,  inviting  hemorrhage.  As  soon 
as  the  blood-currents  find  their  way  by  circuitous 
channels  to  the  lower  portion  of  the  injured  vessel,  it 
wells  up  from  the  wound  in  a  continuous  purplish 
Stream,  all  impulse  having  been  lost,  and  also  most  of 
the  oxygen  contained  in  the  blood,  by  the  long,  round- 
about way  which  the  circulation  now  takes.  The 
darkness  of  the  blood  will  depend  upon  the  difficulties 
of  the  circuitous  passage;  the  rule,  however,  is  :  scar- 
let or  arterial  blood  from  the  upper  end  of  the  vessel, 
blood  more  or  less  dark  colored  or  venous  from  its 
lower  end.  It  must  be  remembered,  however,  from 
what  has  been  just  said,  that  the  color  of  the  blood  in 
secondary  hemorrhage  is  no  criterion  of  the  kind  of 
vessel  from  which  it  flows. 

Guthrie  lays  down  the  two  following  rules  as  the 
great  principles  of  surgery,  to  be  observed  in  the  cases 
of  wounded  arteries,  and  which  ought  never  to  be 
absent  from  the  mind  of  the  surgeon  : 

1.  That  no  operation  ought  to  be  performed  upon  a 
wounded  artery  unless  it  bleeds. 

2.  That  no  operation  is  to  be  performed  for  a  wounded 
artery,  in  the  first  instance,  but  at  the  spot  injured,  unless 
such  operation  not  only  appears  to  be,  but  really  is, 
impracticable. 

These  two  aphorisms  are  the  more  particularly  ap- 
plicable to  recent  wounds  of  arteries,  as  we  will  have 
occasion  to  mention  exceptions  to  both  of  these  rules 
when  discussing  the  modified  conditions  of  the  wound 


LIGATION    OF    BLEEDING    VESSELS.  191 

and  wounded  in  reference  to  cases  of  secondary  hem- 
orrhage. 

When  it  is  necessary  toligale  ail  artery,  the  surgeon 
must  be  guided,  in  finding  it,  by  his  anatomical  knowl- 
edge, and  also  by  the  pulsation.  Tn  dilating  the  wound 
so  as  to  expose  the  bleeding  mouths,  the  incisions 
should  be  made  parallel  to  the  course  of  the  vessel,  and 
Sufficiently  free  to  facilitate  the  search.  The  dissec- 
tion is  carefully  conducted,  dividing  layer  by  layer, 
and  avoiding  the  nerves  and  veins  which  always  ac- 
company the  largo  arteries.  When  the  bleeding 
mouth  is  so  exposed  that  the  origin  of  the  jet  of  blood 
is  seen,  the  vessel  is  transfixed  by  a  tenaculum,  drawn 
out,  and  secured  as  it  would  be  in  a  stump  after  am- 
putation. 

Where  it  is  impossible  to  ligatc  the  bleeding  vessel 
at  the  point  wounded,  a  point  should  bo  selected,  at 
which  the  vessel  is  comparatively  isolated,  easily  dis- 
covered, and  free  from  large  collateral  branches.  In 
exposing  it,  make  a  free  incision.  The  common  error 
that  most  surgeons  commit  is  in  making  a  small  inci- 
sion, which  hampers  the  search.  When  we  approach 
the  artery,  use  the  grooved  director  to  isolate  those 
cellular  layers  in  which  the  vessel  is  always  found. 
The  point  of  the  knife  should  never  be  used  for  this 
purpose.  The  lips  of  the  wound  should  be  drawn 
asunder  by  an  assistant,  so  as  to  give  to  the  operator 
the  light  necessary  for  accomplishing,  speedily  and 
successfully,  the  ligation.  In  all  cases  requiring  such 
an  operation,  it  is  desirable  to  have  the  patient  com- 
pletely under  control,  and,  therefore,  chloroform 
should  be  administered. 

When  the  artery  is  found   and  the  ligature  passed 

under  it,  before  tying  it  be  quite  sure  that  it  is  the 

I,  and  it  alone,  and  not  the  nerve,  that  has  been 


192  LOCAL    TREATMENT    OF    WOUNDS. 

seized.  To  be  satisfied  on  this  point  it  is  only  neces- 
sary to  draw  slightly  upon  the  thread,  and  examine 
above  and  below  it  to  see  whether  the  pulsation  has 
altogether  ceased  below  the  ligature.  Having  deter- 
mined  that  the  thread  is  properly  placed,  it  is  then 
firmly  tied.  The  ends  are  brought  out  of  the  wound 
and  secured  under  a  strip  of  adhesive  plaster,  attach- 
ed to  the  immediate  neighborhood  of  the  wound. 
This  mode  of  disposing  of  the  ligature  will  protect  it 
from  becoming  entangled  in  the  ordinary  dressing,  and 
from  being  drawn  upon  when  those  are  daily  removed. 
Water  dressings  form  the  proper  after- treatment. 
The  thread  will  come  away  spontaneousl}',  by  the 
eighth,  twelfth,  or  sixteenth  day,  according  to  the  size 
of  the  vessel  ligated. 

Local  Treatment  of  Wounds. — Having  removed  all 
foreign  bodies,  and  hemorrhage  having  ceased,  the 
dressing  now  required  should  be  of  the  simplest  de- 
scription. It  is  known  that  gunshot  wounds,  belong- 
ing to  the  contused  variety,  show  a  constant  disposition 
to  suppurate,  and  often  to  slough.  This  process  of  sup- 
puration is  not  necessary  to  the  healing  of  the  wound,  and 
should  be  kept  in  subjection  as  much  as  possible.  This  is 
effected  by  the  continued  application  of  cold  water, 
which,  by  keeping  down  excessive  reaction,  and  keep- 
ing out  an  excess  of  blood,  diminishes  the  source  of  the 
purulent  supply,  and  thus  hastens  the  cure.  In  former 
times,  suppuration  was  considered  essential  in  the 
healing  of  all  wounds,  by  permitting  the  escape  of 
so  much  poisonous  matter,  which  had  accumulated  in 
the  system,  and  which  must  either  now  find  a  vent,  or, 
if  retained,  would  be  considered  the  satisfactoiy  cause 
of  any  sickness  from  which  the  wounded  man  may 
hereafter  suffer.     The  wound  was,  therefore,  under  this 


WATER   DRESSING!    FOR    WOUNDS'.  193 

exploded  belief,  plugged  with  a  tent,  piles  of  greasy 
lint  in  cushions  were  applied,  and,  after  covering  with 
a  sufficient  number  of  compresses  and  bandages,  a 
forcing  bed  was  formed,  which  supplied  pus  to  the 
satisfaction  of  all  interested.  It  was  common  enough, 
under  such  treatment,  to  sec  life  drain  away  from  this 
opening. 

This  smothering  of  wounds  in  hot  poultices,  ffhd  the 
smearing  on  of  greasy  ointments,  which  the  wounded 
formerly  encountered,  was  a  second  enemy,  far  moro 
fatal  than  the  enemy  on  the  battle-field — as  in  its 
ranks  were  found  exhausting  suppuration,  with  its 
hectic;  pyeemia,  with  its  vapid  poisoning;  hospital 
gangrene,  with  its  fatal  collapse,  and  erysipelas,  with 
its  thousands  of  victims  ;  broken-down  constitutions, 
tedious  convalescence,  and  very  protracted  cures,  with 
endless  pains  and  annoyances. 

How  much  moro  rational  is  the  present  practice! 
Keep  away  all  hot  dressings,  which  invite  blood  to  the 
part.  Vote  poultices  and  greasy  pledgets  a  curse,  and 
eject  the  dirty,  troublesome  applications.  Guthrie 
says  poultices  should  not  be  permitted  in  a  military 
hospital ;  they  are  generally  cloaks  for  negligence, 
and  sure  precursors  of  amputation  in  all  serious  inju- 
ries. With  more  recent  writers  they  even  meet  with 
less  favor,  and  the  very  extensive  experience  of  the 
Confederate  hospitals  confirms  this  opinion. 

The  only  dressing  required  for  wounds,  of  whatever 
character,  is  the  water  dressing,  and  it  should  be  used  as 
follows  :  apply  a  single  thickness  of  wet  linen  or  cotton 
cloth  over  the  wound,  allowing  it  to  extend  over  a  con- 
siderable surface.  If  possible,  cover  this  with  a  layer 
of  oiled  silk,  waxed  cloth,  or  india-rubber  tissue.  A 
second  layer  of  cloth  or  a  band  secures  the  two  former 
layers  in  position,  so  that  they  will  not  be  displaced  by 
Q 


194  WATER    DRESSING    FOR    WOUNDS. 

tho  movements  of  the  patient  in  sleeping.  Then 
either  squeeze  cold  water  frequently  upon  this  outer 
cloth,  which  will  keep  up  the  low  temperature;  or 
adopt  the  much  more  convenient  and  less  laborious 
plan  of  suspending  a  bucket,  or  some  vessel  contain- 
ing water,  in  the  neighborhood  of  the  wound,  having  a 
narrow  slip  of  cloth,  or,  what  is  better,  a  lamp  wick 
passing  through  a  hole  in  the  bottom  of  the  suspended 
vessel  to  the  bandage  upon  the  wounded  limb.  By  ca- 
pillary attraction,  a  constant  stream  of  water  is  car- 
ried from  tho  vessel  to  the  dressing,  and,  by  its  evapo- 
ration— robbing  the  skin  of  its  animal  temperature 
to  get  a  sufficient  quantity  of  heat  to  convert  the 
Avater  into  aqueous  vapor — refrigerates  tho  limb.  Tho 
wick  must  run  freely  through  the  hole,  but  not  too 
loosely,  or  tho  water  will  flow  out  too  rapidly.  If 
it  passes  through  snugly,  so  as  to  block  up  the  orifice, 
capillary  action  will  not  draw  oft'  the  water,  and  tho 
parts  will  not  be  irrigated.  The  advantage  of  using 
oiled  silk,  waxod  cloth,  or  india-rubber  tissue  is,  that 
should  the  supply  of  water  accidentally  give  out  in  the 
suspended  vessel,  as  it  frequently  would  do,  from  inat- 
tention of  nurses,  the  picco  of  cloth  beneath  it  remains 
moist  upon  the  wound.  The  wet  cloth  absorbs  tho 
discharges,  and  should  bo  changed  two  or  three  times 
a  day,  it  being  well  understood  that  they  be  disturbed 
as  seldom  as  possible,  compatible  with  cleanliness. 

At  a  very  recont  meeting  of  the  society  of  army 
surgeons,  held  at  Richmond,  the  subject  for  discussion 
being  the  use  of  cold  water  dressings  in  the  treatment 
of  gunshot  wounds,  with  but  very  few  dissenting 
voices,  unanimous  assent  was  given  to  the  judicious 
use  of  cold  water  as  the  only  proper  local  application 
for  wounds.  Tho  past  two  years  in  the  Confederate 
hospitals  have  given  more  extensive  opportunities  for 


WATER    DRESSING    FOR   WOUNDS.  195 

testing  the  advantages  of  water  dressings  than  had 
ever  previously  been  offered  since  the  introduction  of 
this  mothod  as  a  remedial  agent.  The  wounded  who 
have  been  brought  under  its  happy  influences  can 
be  numbered  by  tens  of  thousands,  and  the  magic 
effects  of  this  dressing,  when  judiciously  used,  and  the 
consequent  high  esteem  in  which  it  is  deservedly  held 
by  all  army  surgeons,  has  established,  above  all  cavil, 
its  superiority  over  all  other  dressings. 

Like  all  good  remedies,  it  is  capable  of  much  abuse, 
and  yet  it  is  so  simple,  and  even  when  misused,  doing 
Comparatively  but  little  mischief,  that  its  application 
has  been  put  into  the  hands  of  every  wounded  patient. 
In  applying  it  judiciously,  it  is  not  necessary  to  have 
the  patient  swimming  in  water.  When  the  wound  ex- 
ists upon  the  limbs,  the  bod  can  be  so  arranged  that  tho 
water  as  it  is  conveyed  to  the  wounded  will,  when 
it  has  refreshed  the  patient  by  its  cool  temperature,  run 
off  into  some  receptacle,  without  spreading  over  tho 
bed  and  wetting  all  the  clothing  of  tho  patient.  A 
piece  of  oiled  or  india-rubber  cloth  is  usually  placed 
under  the  wounded  limb  to  protect  tho  clothing  of  tho 
bed  and  patient.  When  the  wound  is  seated  upon  the 
trunk,  it  would  be  dangerous  as  well  as  very  annoying 
to  tho  patient  to  have  a  stream  of  water  running  over 
his  person;  therefore  cloths,  rinsed  frequently  in 
cold  water,  to  be  changed  as  often  as  they  becomo 
warm,  takes  the  place  of  irrigation,  and  is  the  proper 
method  of  applying  cold  water  dressings.  Cold  wa- 
in-applications  are  advantageously  applied  to  wounds 
immediately  after  they  have  been  received,  and  are 
only  contraindicatcd  by  oxisting  shock.  As  long  as 
marked  nervous  depression  is  present,  cold  applica- 
tions would  tend  to  increase  this  serious  complication  ; 
nor  are  there  any  indications  for  its  use  under  these 


11)6  WATER    DRESSING    FOR    WOUNDS. 

circumstances,  us  there  would  be  neither  hemorrhage 
to  be  checked,  pain  to  be  soothed,  nor  nervous  irrita- 
tion and  vascular  excitement  to  be  controlled.  It 
is  only  when  reaction  is  being  established  that  the  ad- 
vantages of  cold  applications  bocoine  apparent.  In 
cases  where  nervous  shock  does  not  accompany  the 
injury,  cold  water  can  not  be  applied  at  too  early  a 
period  to  wounds. 

The  surgeon  should  never  be  in  haste  to  change  t/tecoid 
for  warm  applications.  Should,  however,  in  the  course 
of  treatment,  the  virtues  of  a  poultice  bo  called  into 
requisition,  a  soft,  wet  compress,  covered  with  oiled 
silk  or  india-rubber  tissue,  and  secured  by  a  flannel 
roller  or  outer  compress,  will  be  found  to  combine,  in 
a  simple  form,  all  the  properties  of  a  poultice.  It  is 
light,  moist,  soft,  and  is  kept  warm  by  absorbing  ani- 
mal heat,  which  the  oiled  silk  and  outer  compress 
retain.  If  wo  add  to  these  properties  cleanliness,  fa- 
cility of  medication,  and  the  readiness  with  which  an 
impromptu  dressing  can  be  made,  we  find  an  array  of 
advantages  which  exclude  all  substitutes. 

A  more  effectual  mode  of  keeping  down  reaction  is, 
b}T  using  ice  bladders,  which  are  placed  upon  the  india- 
rubber,  waxed,  or  oiled  silk  covering.  These  arc  of 
very  general  application,  and  make  the  least  call  upon 
the  personal  attention  of  nurses.  Whenever  ice  is  used, 
never  apply  it  directly  to  the  skin,  but  always  through  the 
intervention  of  compresses,  which  may  be  made  suffi- 
ciently thick  to  accommodate  the  application  to  the 
sensitiveness  of  the  patient.  When  possible,  these 
bladders  should  be  of  india-rubber  or  gutta-percha,  as 
such  materials  are  impermeable  to  water  and  permit 
of  water  applications  for  the  reduction  of  temperature, 
at  tho  same  time  keeping  the  body  and  bedclothing 
dry — a  very  great   desideratum.     A  large  supply  of 


ADVANTAGES    OF    WATER    DRESSING.  197 

those  should  always  he  on  hand.  The  animal  bladder 
is  a  miserable  substitute,  as  it  is  not  only  a  very  dirty 
application,  allowing  the  water  to  ooze  out  and  keep 
the  patient  constantly  wot,  but  the  bladders  soften 
and  decompose,  becoming  very  offensive,  and  arc  soon 
destroyed. 

Cold  water  is  the  only  proper  and  universal  antiphlo- 
gistic that  can  be  applied  to  wounds.  It  has  the  conven- 
ience of  always  being  at  hand,  it  keeps  up  a  uniform  ac- 
tion, is  clean,  simple,  cheap,  agreeable  to  the  feelings 
of  the  patient,  easily  obtained,  easily  applied,  demands 
least  care  from  the  nurses,  who  have  their  hands 
usually  full,  and  is  withal  effectual.  With  the  judicious 
application  of  cold  water  the  surgeon  can  defy  inflamma- 
tion. Cold  acts  by  keeping  down  temperature  and 
constringing  vessels,  thereby  keeping  blood  from  the 
part  injured;  so  that  inflammation,  which  consists  in 
the  engorgement  of  blood-vessels  and  an  excessive 
supply  of  blood,  can  not  gel  a  foothold.  Heat,  redness, 
pain,  and  swelling,  all  depend  upon  congestion  ;  con- 
trol the  supply  of  blood  to  a  part,  and  inflammation  is 
kept  in  abeyance.  It  also  acts  directly  upon  the  ner- 
vous element  of  the  tissues,  by  its  local  sedative  effect, 
blunting  sensibility,  allaying  pain,  removing  irritation, 
and  thereby  the  excitement  in  the  circulation. 

As  the  advantages  of  cold  water  dressings  are  ob- 
tained through  the  evaporating  properties  of  water, 
this  action  may  bo  increased  by  medicating  it  with  sa- 
line substances  or  alcoholic  tinctures.  Sugar  of  lead, 
sulphate  of  zinc,  tannin,  muriate  of  ammonia,  lauda- 
num, spirits  of  camphor,  and  especially  tincture  of 
arnica,  would  be  useful  adjuvants.  Some  surgeons 
consider  any  addition  as  detrimental  to  the  efficacy  of 
simple  water;  but.  unfortunately,  simplicity  is  but 
little  in  accordance  with  the  popular  taste. 


198  ADVANTAGES   OF    WATER   DRESSING. 

While  the  irrigation  is  going  on,  the  compresses 
next  the  Bkin  may  bo  moistened  every  three  or  four 
hours  with  any  of  the  above  preparations.  There  arc  a 
few  persons  to  whom  the  application  of  cold  water  is 
inadmissible.  In  every  ease  the  feelings  of  the  patient 
will  be  our  guide  as  to  the  applicability  of  the  remedy. 
When  not  grateful  and  refreshing  to  the  patient,  but, 
on  the  contrary,  the  cause  of  complaints,  with  tenden- 
cies to  chilliness,  the  irrigation  must  be  superseded  by 
a  wet  compress,  covered  with  oiled  silk  or  a  waxed 
cloth.  This  will  soon  attain  the  temperature  of  the 
body,  and  will  keep  the  parts  moist  and  soft.  The 
dressing  requires  to  be  changed  three  or  four  times  in 
twenty-four  hours;  not  that  the  compress  would  get 
dry,  for  the  perspiration  from  the  part,  and  discharges 
from  the  wound,  which  are  kept  in  by  the  oiled  silk, 
would  bathe  it  in  a  continual  and  permanent  moisture. 
The  object  in  renewing  the  wet  cloths  is  to  get  rid  of 
these  secretions,  which,  in  decomposing,  would  irritate 
the  wound. 

A  question  of  great  moment  is,  token  should  we  desist 
from  water  applications,  and  change  for  some  more  useful 
or  appropriate  dressing?  According  to  the  present 
rational  views  of  surgeons,  no  other  drossing  is  over 
required,  however  serious  the  wound  may  be.  As 
long  as  inflammation  threatens,  so  long  is  it  necessary 
to  prevent  engorgements.  As  long  as  suppuration  is 
kept  up,  so  long  will  the  efficacy  of  cold  be  required  to 
constringe  the  blood-vessels  and  control  the  source  of 
the  purulent  supply. 

Pus,  which  we  call  a  healthy  fluid,  is  a  heavy  drain 
upon  the  system.  It  is  made  from  the  richest  ingredi- 
ents of  the  blood,  which  were  intended  for  the  repair 
of  tissues.  Once  converted  into  pus,  it  is  unfit  for  any 
further  useful  purpose,  and  is,  therefore,  a  waste  of 


ABUSES    IN    COLD    WATER   DRESSING.  199 

precious  material.  This  discharge  is  not  more  neces- 
sary to  the  healing  of  wounds  than  to  the  nutrition  of 
tho  body.  Extensive  wounds,  healing  by  the  first 
intention,  do  very  well  without  its  intervention. 
Large  subcutaneous  wounds,  when  even  their  sides 
are  not  kept  in  apposition,  heal  with  rapidity  without 
the  formation  of  pus.  Under  a  scab  we  find  tissues 
form,  by  what  has  been  called  the  remodelling  process, 
without  it;  and  it  should  be  our  constant  effort  to 
lieal  all  wounds,  and  I'  would  say,  especially  gunshot 
wounds,  with  the  least  possiblo  discharge.  Hence  the 
water  dressing  can  be  continued  beneficially  for  weeks, 
or  as  long  as  the  wound  remains  unhealed.  Our  ex- 
perience in  the  treatment  of  gunshot  wounds,  which 
accords  with  that  of  most  army  surgeons,  is  that  the 
wet  cloth  should  be  kept  on  until  cicatrization  is  com- 
pleted; and  that  no  other  application  so  protects  and 
promotes  the  formation  of  new  skin. 

I  would,  however,  call  attention  to  a  general  cause 
of  annoyance  in  the  use  of  water  dressing.  The  main 
object  of  the  cold  water  application  is  to  prevent  or 
control  inflammatory  action  in  the  wound  and  its  vi- 
cinity. Whenever  all  the  sj-mptoms  of  inflammatory 
excitement,  viz:  heat,  redness,  pain,  and  swelling — 
have  subsided,  leaving  a  wound  which  suppurates  but 
little  in  a  limb  of  normal  size  and  appearanco,  the  ap- 
plication of  cold  water,  by  irrigation,  has  fulfilled  its 
duty,  and  is  no  longer  beneficial.  If  the  entire  sia*- 
face  of  the  limb  should  now  be  kept  enveloped  in  wet 
cloths  the  skin  becomes  irritable,  tho  sebacious  folli- 
cles take  on  suppurative  inflammation,  and  crops  of 
very  annoying  boils,  accompanied  by  interminable 
itching,  Bucceed  each  other  with  persistent  regularity^ 
until  the  dressing  is  changed.  When  the  symptoms 
of  inflammatory  excitement  have  disappeared  from 


200  MEDICATED   WATER    DRESSING. 

the  wound,  which  i'n  simple  gunshot  wounds  is  usual- 
ly about  the  tenth  day,  instead  of  continuing  tho 
water  dressing  over  a  large  surface  of  the  limb,  con- 
fine its  application  to  a  small  compress  over  and  im- 
mediately around  the  wound;  cover  this  with  a  piece 
of  oiled  silk,  only  a  little  larger  than  the  compress, 
and  secure  both  in  position  by  a  bandage — the  wet 
cloth  to  be  renewed  two  or  three  times  a  day.  The 
oiled  silk  keeps  the  cloth  moist,  preventing  the  secre- 
tions from  drying  and  forming  a  hard,  painful  crust 
over  the  wound,  which,  by  retaining  the  secretions, 
would  become  the  cause  of  pain.  By  retaining  the 
moisture  it  also  prevents  the  cloth  from  adhering  to 
the  edges  of  the  wound,  and  thereby  not  only  saves 
the  patient  much  pain  at  the  renewal  of  the  dressings, 
but  avoids  the  injury  to  the  granulations.  This  is  re- 
cognized, after  the  removal  of  dressings  carelessly 
applied,  by  the  bleeding  from  the  surface,  and  more 
particularly  the  edges  of  the  wound,  where  the  new, 
delicate  skin  is  forming,  and  which,  if  rudely  torn  day 
after  day  by  cloths  adhering  to  the  wound,  will  cause 
it  to  take  on  an  irritable  or  indolent  condition  which  .  % 
is  averse  to  healing. 

There  are  a  long  list  of  ointments  which  have  here- 
tofore held  universal  sway  in  the  treatment  of  wounds, 
among  which  simple  cerate  is  the  most  conspicuous. 
Although  this  is  a  simple  and  innocent  preparation, 
as  its  name  indicates,  and  is  extensively  used  in  the 
army  as  an  application  to  chronic  wounds,  even  this 
can  be  dispensed  with  for  the  more  simple  water 
dressing.  Should  the  wound  require  stimulation,  the 
nitrate  of  silver  wash,  grs.  xx  to  the  ounce,  when 
brushed  over  the  part,  will  suffice;  or  tincture  of 
iodine,  or  iron,  or  some  stimulating  astringent,  might 
be  equally  applied  in  addition   to  the  water  dressing, 


DISTURBING    INFLUENCES    OF   WOUNDS.  201 

so  that  any  imaginary  condition  of  the  wound  might 
be  successfully  met  by  the  medicated  wet  cloth. 

The  disturbing  influences  in  the  healing  process  of 
wounds  are  numerous,  and  most  of  them  are  capablo 
of  correction  without  much  trouble.  Among  these 
arc  found  imperfect  transportation  over  rough  roads 
in  improper  vehicles ;  bad  attendance,  including  rough 
or  too  frequent  examinations;  useless  and  excessive 
bandaging,  which  promotes  infiltration;  too  frequent 
dressing;  improper  food;  scorbutic,  syphilitic,  and 
other  diseases;  the  moral  depression  of  defeat;  and, 
above  all,  imperfect  ventilation  and  insufficient  regard 
to  cleanliness,  and  over-crowding  in  the  wards  of  mili- 
tary hospitals. 

We  have  already  said  that  a  surgeon  is  never  war- 
ranted in  cutting  down  upon  an  artery  and  tying  it 
upon  suspicion;  he  must  be  an  e}Te-witness  of  the 
hemorrhage,  and  see  that  it  can  not  be  controlled  by 
other  means.  The  ligation  of  an  artery  is  always  a 
troublesome  operation,  and,  from  the  fear  of  subse- 
quent mortification,  always  jeopards  the  limb,  and 
necessarily  with  it  the  life  Of  the  patient.  This  is 
especially  the  case  in  recent  wounds,  before  nature 
has  prepared  a  collateral  circulation;  so  that  the  rule 
which  we  have  laid  down  is  imperative,  as  far  as  it 
relates  to  recent  wounds — never  ligate  an  artery,  how- 
ever large,  in  which  hemorrhage  has  spontaneously  ceased. 
Moreover,  a  good  compress  is  usually  sufficient,  when 
applied  immediately  after  the  receipt  of  injury  on  the 
battle-field,  to  stop  the  bleeding  even  from  the  largest 
vessel;  and  position,  quiet,  rest,  and  other  prophylac- 
tics, will  most  frequently  prevent  its  return. 

It  has  often  happened  that,  after  an  injury  had  been 
inflicted  upon  an  artery  of  large  size,  the  rapid  flow  of 
blood  from  the  wound  had  brought  on  syncope,  which 


202  CONTROLLING    PRIMARY    HEMORRHAGE. 

was  more  or  less  prolonged,  followed  by  nervous  .shock 
and  a  depressed  condition  of  the  nervous  system  of 
considerable  duration.  It  is  under  such  influences, 
controlling  all  activity  in  the  circulation,  that  the 
bleeding  ceases  spontaneously  and  clots  of  blood  form. 
Should  a  person  suffering  from  such  an  injury  be  not 
disturbed  by  rough  transportation,  nor  be  too  freely 
stimulated,  the  blood  forms  firm  clots,  which  may 
close  up  the  orifices  in  the  injured  vessel,  and  become 
so  blended  with  the  tissues  as  not  to  be  displaced,  and 
no  further  trouble  ensues.  It  is  on  this  account  that 
the  unavoidable  delay  of  removing  the  seriously 
wounded  from  battle-fields  becomes  a  blessing.  In 
running  over  the  field  after  a  severe  battle,  those 
who,  from  loss  of  blood,  have  not  the  strength  to  cry 
for  help,  are  left  as  mortally  wounded  by  the  mem- 
bers of  the  ambulance  corps,  who  are  busily  engaged 
in  carrying  to  the  infirmary  those  whom  they  think 
require  immediate  attendance,  and  are  likely  to  be 
benefited  by  treatment.  When  all  of  these  have 
been  removed,  the  battle-field  is  again  gleaned  for 
such  as  may  be  found  alive  after,  perhaps,  an  inter- 
val of  from  twenty-four  to  forty-eight  hours.  The 
quiet  of  the  battle-field  has  supplied  to  the  severelj- 
wounded  such  treatment  as  they  required,  ami  under 
judicious  care  these  cases  often  do  well.  Should  such 
wounded  be  disturbed  soon  after  the  flow  of  blood 
had  ceased,  and  be  transported  to  the  infirmary  or 
general  hospital,  and  especially  if  brandy  be  freely 
given  to  bring  on  reaction,  the  excitement  which  the 
pulse  would  exhibit,  and  the  increased  force  of  the 
heart's  action,  would  displace  the  clots  before  they  be- 
came firmly  established  in  the  site  of  the  wound,  and 
hemorrhage  would  reappear. 

This  renewal  of  the  bleeding,  as  a  variety  of  consec- 


SECONDARY    HEMORRHAGE.  203 

utive,  is-  called  retarded  hemorrhage,  and  is  simply 
a  continuation  of  the  primary  hemorrhage,  after  an 
interval  of  a  few  hours'  suspension,  before  the  artery 
and  surrounding  tissues  have  undergone  any  material 
changes.  Although  a  ligature  upon  the  bleeding 
mouths  of  the  vessel  in  the  wound  may  be  necessary 
to  arrest  this  bleeding,  when  excessive  and  threaten- 
ing the  life  of  the  wounded  man,  as  a  rule  judicious 
pressure  and  the  use  of  styptics  are  found  adequate 
for  its  control. 

In  the  ordinary  course  of  gunshot  wounds,  suppu- 
ration is  established  about  the  fifth  or  sixth  day,  when 
the  track  of  the  wound  commences  to  be  cleansed  of 
all  those  tissues  which  have  been  crushed  and  so 
much  injured  as  to  bo  no  longer  preserved  among 
the  living  tissues.  During  the  elimination  of  these 
destroyed  parts,  when  the  walls  of  blood-vessels  are 
implicated,  and  where  the  precaution  of  rest  and  abso- 
lute quiet  has  not  been  enforced,  hemorrhage,  called 
secondary,  appears.  All  injuries  to  large  arteries 
threaten,  sooner  or  later,  to  produce  secondary  hem- 
orrhage. However  large  the  artery  reopened  by  this 
process,  the  escape  of  blood  seldom  occurs  with  an 
impulse,  but  usually  flows  away  in  a  continuous 
stream,  which  is  supposed  to  indicate  its  escape  from 
the  lower  end  of  the  vessel. 

If  hemorrhage  has  been  arrested  for  a  few  hours, 
when  even  from  the  femoral  artery,  the  efforts  of 
nature  are  usually  sufficient  to  prevent  its  return 
from  the  upper  portion  of  the  artery,  although  not 
from  the  lower  end  of  the  vessel;  so  that  when  the 
main  artery  of  a  limb  is  divided  by  a  ball,  should 
primary  hemorrhage  be  controlled,  the  great  fear  is 
either  from  subsequent  bleeding  through  the  lower 
ond  of  tho  vessel,  or   from  mortification    of  the    ex- 


204  CAUSES    OF    SECONDARY    HEMORRHAGE. 

tvcniity.  Any  hemorrhage,  ufter  forty-eight  hours, 
would  be  considered  secondary,  and  would  require 
special  treatment;  prior  to  this  it  would  be  called 
retarded  or  delayed  primary  hemorrhage.  As  long 
as  the  wound  remains  unhealed,  hemorrhage  may 
make  its  appearance;  and  it  is  not  until  a  cure  is 
effected,  and  the  parts  are  cicatrized,  that  the  patient 
is  positively  safe  from  this  dangerous  complication. 
Cases  are  recorded  where  it  has  occurred  ninety  days 
after  the  vessel  had  received  injury;  and  a  case  of  un- 
usual interest  has  recently  been  reported  bj7-  Surgeon 
S.  E.  Habersham,  in  the  Confederate  States  Medical 
and  Surgical  Journal,  for  January,  1804,  in  which  ar- 
terial hemorrhage  destroyed  life  three  hundred  and 
twenty-eight  days  after  the  receipt  of  wound.  The 
case  was  one  of  compound  fracture  of  the  upper  third 
of  the  thigh  from  gunshot  woivfld,  in  which  a  detach- 
ed fragment  from  the  femur  finally  caused  ulceration 
in  the  femoral  artery,  and  fatal  hemorrhage  occurred 
through  existing  fistula1,  which  were  still  discharg- 
ing. 

Unless  the  causes  of  this  hemorrhage  be  perfectly 
understood,  the  rules  laid  down  for  treatment  will 
not  bo  duly  appreciated.  In  speaking  of  the  action 
of  the  two  ends  of  a  divided  artery,  we  have  already 
stated  that  the  upper  cud  contracts  vigorously,  dimin- 
ishes its  calibre  at  the  point  divided,  and  for  some 
distance  up  the  tube,  until  it  simulates  in  its  propor- 
tions the  neck  and  body  of  a  claret  bottle.  The 
blood,  impeded  in  its  outward  course,  allows  a  clot  to 
form,  which,  acting  as  a  stopper,  shuts  up  the  open 
mouth.  The  clot  of  blood,  as  a  plug,  is  continued  in 
the  contracted  artery  to  the  first  collateral  branch, 
and  nearly  fills  this  cylinder.  The  lower  portion  of 
the  vessel,  having  been  in  a  measure  paralyzed  by 


CAUSES   OF   SECONDARY    HEMORRHAGE.  205 

the  division  of  its  coats,  which  had  cut  off  its  supply 
of  nerves,  acts  with  much  less  energy.  The  diminu- 
tion of  its  calibre  depends  more  upon  the  removal  of 
distension  from  its  elastic  walls  than  from  the  con- 
traction of  its  muscular  fibres.  The  result  of  this 
paralysis  is,  a  more  or  less  patulous  condition  of  the 
lower  portion  of  the  vessel  in  the  vicinity  of  the  inju- 
ry; and  as  the  supply  of  blood  from  above  is  cut  off, 
there  is  but  little  arterial  blood  in  it  to  clot  and  ping 
it  up. 

As  soon  as  this  barrier  or  clot  is  placed  upon  tho 
main  thoroughfare,  at  the  upper  wound,  preventing 
the  blood  from  following  its  accustomed  channel, 
nature  is  at  oiu-c  busy,  opening  and  enlarging  the  cir- 
cuitous by-ways  and  alle}-s  of  the  circulation,  so  as  to 
restore  the  supply  to  the  extremity  threatened  with 
starvation,  or,  in  surgical  parlance,  mortification.  (Hoc 
figure  4,  plate  14.)  As  when  upon  a  high-road  abridge 
spanning  a  stream  is  destroyed,  travellers  seek  a  ford 
higher  up  by  which  they  may  return  to  the  thorough- 
fare beyond  the  impediment,  so  the  blood,  taking  the 
nearest  by-roads  above,  soon  gets  around  the  obsta- 
cle, and  empties  itself  into  the  main  channel  below  it. 
The  blood  here  changed  in  its  direction,  "and  not 
opposed  by  valves,  passes  up  as  well  as  down  the 
Hmb,  and  finding  an  open  gate  at  the  lower  torn 
mouth  of  the  vessel,  escapes.  This  fluid,  moreover,  in 
its  roundabout  course,  has  lost  much  of  its  vivifying 
properties;  much  of  its  oxygen  is  gone,  and  carbonic 
acid,  ammoniacal  gases  and  the  like,  having  taken  its 
place,  mars  its  brilliant  color,  and  diminishes  its  clot- 
ting properties.  No  proper  material,  therefore,  exists 
for  stopping  rip  the  vessel,  as  in  the  upper  end  of  the 
divided  artery,  and  the  vosult  is  that  secondary  hem- 
orrhage may  readily  occur  from  the  lower  end. 


2U6  LIOATE    BOTH    ORIFICES. 

This  being  well  understood,  wo  can  now  explain 
why  a  ligature  placed  on  the  upper  orifice  alone,  or  on 
the  course  of  the  artery  above  the  injury,  should  not 
always  stop,  but  often  only  temporarily  control,  the 
hemorrhage.  As  Boon  as  the  collateral  circulation  above 
the  ligated  point  is  re-established,  should  (he  lower 
opening  in  the  vessel  remain  ae  before,  a  sufficient  in- 
terval not  having  elapsed  for  the  gradual  contraction 
and  obliteration  of  the  arterial  tube,  hemorrhage  must 
recur,  or,  if  this  collateral  circulation  be  not  establish- 
ed, mortification  must  follow.  The  rule  which  experi- 
ence has  established  from  these  physiological  and  patho- 
logical/acts is:  ligate  both  ends  of  the  vessel  at  the  point 
wounded,  as  this  is  the  safest  course  to  pursue. 

Another  strong  reason  why  the  ligature  should  be 
applied  to  the  wounded  ends  of  tho  artery  is,  that  there 
is  always  some  uncertainty  as  to  the  vessel  injured, 
whether  it  be  the  main  trunk  or  only  a  branch.  The 
very  serious  and  often  fatal  operation  of  ligating  the 
femoral  artery  has  been  performed  for  an  injury  to  one 
of  its  branches,  which  had  not  been  suspected — a  post- 
mortem examination  revealing  the  source  of  hemor- 
rhage. When  the  ligature  is  applied  to  the  bleeding 
mouths'this  accident  can  not  happen. 

A  very  interesting  case  in  point,  which  brings  the 
propriety  of  the  above  rule  strongly  into  view,  was 
that  of  Private  13.  Creeey,  Company  E,  42d  Virginia 
regiment,  who  was  wounded  on  tho  3d  of  .May,  1863, 
by  a  minie  ball,  which,  in  its  passage  through  the 
larynx,  above  tho  vocal  cords,  carried  away  the  epi- 
glottis. On  the  twelfth,  nine  days  after  the  receipt  of 
injury,  while  under  treatment  in  the  Winder  Hospital, 
a  severe  secondaiy  hemorrhage  came  on,  to  control 
which  tho  left  common  carotid  artery  was  ligated. 
Tho  hemorrhage  ceased,  to  reappear  on  the  eighteenth, 


TREATMENT    OF    SECONDARY    HEMORRHAGE.         207 

when  the  right  common  carotid  artery  was  Iigated, 
with  the  same  effect  of  stopping  the  bleeding.     The 

patient  lived  thirty-six  hours  after  the  second  opera- 
tion. An  autopsy  revealed  the  tact  that  the  lefthyoid 
artery  was  the  injured  one,  and  the  inference  is  that  a 
ligature  to  tho  artery  at  the  scat  of  injury  might  have 
given  a  much  more  successful  result,  and  obviated  two 
very  serious  operations. 

The  course  which  should  be  adopted  in  the  ease  of  hem- 
orrhage from  an  injured  artery  is  as  follows:  After  tho 
hemorrhage  has  once  been  controlled,  and  through 
either  carelessness  on  the  part  of  the  surgeon,  or  rest- 
lessness on  the  part  of  the  patient,  getting  up  to  help 
himself  when  he  had  strict  orders  to  the  contrary,  or 
perhaps  from  rough  transportation  over  bad  roads,  or 
the  sloughing  of  the  wound,  or  by  enfeebled  health 
brought  on  by  camp  diseases  or  exposures  in  the  field, 
etc.,  hemorrhage  reappears,  the  limb  should  be  at  once 
bandaged  from  the  extremity  upward,  making  careful, 
regular  pressure,  so  as  to  diminish  tho  quantity  of  cir- 
culating fluid.  Over  the  course  of  the  main  artery, 
and  for  somo  little  distance  above  and  below  the 
wound,  a  compress,  saturated  or  not  with  some  of  the 
styptic  preparations  of  iron,  should  be  firmly  secured, 
the  bandaging  of  tho  limb  extending  to  one  or  two 
inches  above  the  injury.  The  patient  is  then  to  be 
placed  upon  his  back,  the  limb  elevated,  and  an  Ice 
bladdor  applied  over  the  wound.  Absolute  quiet 
should  be  enjoined,  and  secured  by  the  free  adminis- 
tration of  opium. 

In  many  cases  this  plan  of  treatment  will  bring 
about  the  desired  object  if  pei*sevcred  in  for  some  time, 
and  assisted  by  those  internal  remedies  which  control 
the  force  of  tho  circulation,  as  veratium  viride  and 
digitalis,  in  connection  with  such  a  course  as  will  im- 


l!08         LIGATURE    FOR   SECONDARY    HEMORRHAGE. 

prove  the  plastic  character  of  the  blood,  viz  :  tonics, 
good  food,  etc.  By  the  use  of  compresses  saturated 
with  the  perchloride  of  iron,  in  connection  with  abso- 
lute rest,  I  have  succeeded  in  checking  secondary 
hemorrhage  from  the  carotid  artery  after  tbe  escape 
of  the  ligature. 

But  should  the  parts  be  so  situated  that  this  press- 
ure can  not  be  applied  for  a  sufficiently  long  time,  or 
should  it  not  control  the  bleeding,  or  should  the  bleed- 
ing recur,  then  the  proper  course  is  to  attempt  to  save 
the  life  of  the  patient  by  a  surgical  operation.  Ligato 
the  mouths  of  the  artery  in  the  wound  without  further 
delay,  if  it  be  possible.  If  the  artery  can  not  be  found 
at  the  point  from  which  tho  bleeding  occurs,  then 
ligate  it  at  some  portion  of  its  course  above  the  seat  of 
injury. 

No  case  of  secondary  hemorrhage  should  destroy 
life  by  repeated  recurrence j  a  surgeon  is  very  culpa- 
ble who  thus  permits  life  to  ebb  away  from  his  grasp. 

Surgeons  can  not  be  too  much  on  their  guard  against 
the  delusive  attempts  at  stopping  the  bleeding  by 
medication  after  the  second  recurrence  of  secondary 
hemorrhage.  If  the  case  is  not  operated  upon  the 
bleeding  is  sure  to  return,  and  as  certain  to  destroy 
life,  as  experience  has  repeatedly  proved.  Every  fresh 
hemorrhage  increases  the  dangers  and  multiplies  the 
risks.  A  rare  instance  ma}'  occur  in  which  secondary 
hemorrhage,  even  three  or  four  times  renewed,  has 
finally  ceased,  and  the  patient  has  recovered;  but  this 
would  be  a  very  dangerous  example  upon  which  to 
establish  rules  for  treatment,  as  a  very  large  majority 
of  similar  cases  would  be  sacrificed  to  this  procrasti- 
nation. The  established  rule,  therefore,  is  never  to  neglect 
the  ligation  of  an  artery  after  the  second  recurrence  of 
hemorrhage. 


HOW    TO    FIND    BLEEDING    VESSELS.  209 

You  must  not  be  deterred  from  placing  a  ligature  on 
the  open  mouths  of  an  artery  in  a  suppurating  wound, 
on  the  deeply  grounded  but  erroneous  idea  that  the 
artery  has  had  its  coats  softened  by  this  process.  Prac- 
tical surgery  shows  conclusively  that  but  little  press- 
ure is  required  to  close  the  vessel,  and  that  the  coats 
are  tough  enough  to  sustain  a  ligature  in  a  suppurat- 
ing wound.  Therefore  the  rule  should  have  no  ex- 
ception on  this  account.  When  it  is  possible,  ligate  in 
the  wound  under  any  circumstances.  The  swelling  and 
infiltration  of  tissues  renders  the  search  after  the  in- 
jured artery  difficult ;  but  the  surgeon  who,  looking  to 
the  side  of  humanity,  considers  it  a  sacred  duty  to  do 
everything  for  the  interest  of  the  wounded,  must  not 
allow  difficulties  to  interfere  with  his  proper  course. 
Safety  lies  in  this  operation.  When  possible,  the  diffi- 
culties must  be  met  and  overcome. 

There  are  cases,  however,  in  which  these  would  be 
nearly  insurmountable,  where  the  hemorrhage  occurs 
from  an  inaccessible  artery  located  in  parts  which  are 
very  much  swollen,  and  in  a  subject  much  prostrated 
by  previous  loss  of  blood.  In  such  cases  we  are  forced 
to  ligate  the  artery  at  some  point  above  the  site  of 
injury,  where  it  can  be  found  with  facility  and  certain- 
ty, and  where  the  tissues  have  undergone  no  material 
changes. 

The  following  appearances  will  be  observed  in  the 
wound,  and  will  assist  in  the  search  :  After  dividing 
the  infiltrated  tissues,  should  the  injury  have  been  re- 
ceived over  forty-eight  hours — particularly  if  ten  or 
fifteen  days  have  intervened,  which  is  the  usual  pe- 
riod for  the  recurrence  of  secondary  hemorrhage — the 
ends  of  the  vessel  will  be  found  incarcerated  in  the 
midst  of  a  mass  of  greenish  yellow  iibrine,  with  blood 
clots  of  more  or  less  recent  origin.  These  indicate  the 
■ 


210  HOW    TO    FIND    BLEEDING    VESSELS. 

situation  of  the  artery,  the  ('(Mitral  being  the  softosl 
portion  of  the  clot  corresponding  to  the  orifice  in  the 
vessel.  Where  post-mortem  examinations  are  made,  in 
cases  of  death  from  secondary  hemorrhage  in  which 
the  clots  of  former  hemorrhage  have  had  time  to  be 
bleached  by  the  absorption  of  the  colored  portions. 
a  probe  introduced  into  the  artery  from  below  would 
make  its  appearance  at  a  point  under  the  yellow  fibri- 
nous residuary  clot,  raising  a  thin  portion  as  it  pro- 
trudes. Should  the  patient  have  been  destroyed  by 
h  hemorrhage,  an  opening  will  usually  be  found  in 
this  pellicle.  Through  the  upper  portion  of  the  artery 
the  probe  would  pass  down  with  much  more  difficulty, 
owing  to  a  contracted  tube  plugged  with  cougula — 
conditions  which  do  not  exist  in  the  lower  portion. 
These  lymphy,  yellowish  green  fibrinous  masses  are 
to  be  followed  as  our  guides  alter  the  wound  has  been 
freely  dilated. 

The  exact  situation  of  the  incision  to  seek  the 
bleeding  vessel  will  depend  much  upon  the  position 
of  the  wound.  Should  the  ball  have  traversed  in  such 
a  way  as  to  render  the  track  of  the  wound  a  short 
road  to  the  vessel,  the  search  would  be  made  by  dilat- 
ing freely  the  wound.  Where  the  ball  has,  however, 
traversed  the  limb  obliquely,  and  the  orifice  from 
which  the  blood  escaped  is  at  some  distance  from  the 
vessel,  requiring  an  unnecessarily  extensive  incision 
to  expose  the  artery,  it  would  bo  much  preferable, 
instead  of  dilating  the  existing  wound,  to  pass  a  probe 
through  the  track  made  by  the  ball  until  it  reaches, 
apparently,  the  immediate  neighborhood  of  the  bleed- 
ing vessel,  and  then  make  an  incision  parallel  with 
and  directly  over  the  course  of  the  artery  at  a  point 
where  the  vessel  is  most  superficial,  and  where  its 
anatomical   relations  can  be    used  as  guides   in   the 


UUATliRE    ABOVE    THE    INJURY.  211 

search.  If  the  incision  be  free,  which  it  should  al- 
ways be.  a  healthy  portion  of  the  vessel,  both  above 
and  below  the  bleeding  or  injured  portion,  can  bo  ex- 
posed, and  the  pulsation  in  its  course  above  the  in- 
jury would  materially  assist  the  operator  in  finding 
the  torn  or  ulcerated  portion.  As  this  operation  may 
be  called  for  in  a  case  in  which,  should  the  search  fail, 
it  would  be  impossible  or  inexpedient  to  ligatc  the  ar- 
tery in  its  course  above  the  seat  of  injury,  the  incision 
may  be  made  in  such  a  direction  as  would  permit  oT 
an  amputation  being  performed  as  a  dernier  resort. 
When  the  incision  has  exposed  the  vessel,  a  removal 
of  tho  pressure  from  above,  whether  it  be  from  a 
tourniquet  or  the  linger  of  an  assistant,  will  allow  the 
blood  to  escape  from  the  injured  point. 

In  a  surgical  operation,  especially  in  ligating  arte- 
ries, never  be  cramped  from  the  fear  of  making  too 
large  an  opening;  the  error  is  always  on  tho  other 
side.  Having  found  and  ligatcd  the  orifices,  the  wa- 
ter dressing  should  be  continued  as  before — care  be- 
ing taken  not  to  apply  it  should  the  limb  become  cool 
and  pale.  This  is  not  usually  the  case  after  ligations 
for  secondary  hemorrhage,  as  the  return  of  the  bleed- 
ing indicates  a  re7established  circulation,  which  tho 
ligature  at  the  bleeding  mouths  can  not  now  influence 
to  the  injury  of  the  limb. 

Should  it  be  impossible  to  find  the  bleeding  mouths, 
after  a  long  and  careful  search,  or  should  our  experi- 
ence teach  us  that,  from  the  position  of  the  wound,  a 
search  after  the  vessel  at  its  wounded  portion  would, 
in  all  probability,  be  unsuccessful,  then  we  will  be  re- 
luctantly compelled  to  adopt  the  less  satisfactory 
operation  of  ligating  the  artery  above  the  wound — 
hoping  it  may  obviate  any  further  operation.  Often 
ihis  course  succeeds  in  checking  permanently  tho  hem- 


21-         AMPUTATION    NECESSARY    IN    HEMORRHAGE. 

orrhagc.  The  swelling  and  oedema  of  the  limb  rapidly 
subsides,  the  wound  takes  on  healthy  action,  granula- 
tions spring  up,  and  cicatrization  marches  steadily  to 
the  complete  healing  of  the  wound.  In  many  cases, 
however,  when  this  last  plan  has  been  adopted,  a  re- 
turn of  the  hemorrhage  necessitates  a  second  ligature 
upon  some  higher  point;  and  should  this  fail,  as  is 
often  the  case,  amputation  of  the  limb  will  be  the 
only  resort  to  save  life.  Amputation  must  be  equally 
resorted  to  if.  after  the  application  of  a  ligature,  the 
circulation  not  being  re-established,  mortification  of 
the  limb  ensues.  In  either  case  amputate  above  the 
seat  of  the  ligature,  so  as  to  ensure  a  supply  of  blood 
to  the  stump  for  its  nutrition. 

These  are  some  of  the  dangers  incurred  when  the 
surgeon  docs  not  adopt  the  only  proper  course  to  stop 
the  trouble  at  its  commencement.  Military  hospital 
statistics  show  heavy  mortuary  lists  where  this  rule 
is  not  recognized  and  followed.  As  the  ligature  acts 
as  a  foreign  body,  and  must  come  away,  it  is  of  little 
importance  what  is  used  for  that  purpose — a  strong 
cotton,  flax,  or  silk  thread,  fulfils  all  the  indications 
required.  "When  applied,  it  should  not  be  interfered 
with  until  it  has  either  come  away  of  its  own  accord,  or 
ten  to  fifteen  days  have  elapsed,  when  cautious  trac- 
tions might  be  attempted  to  hasten  its  removal. 

Silver  wire  has  been  spoken  of  as  ligatures  for  arte- 
ries. However  well  it  may  answer  in  fresh  wounds, 
where  union  by  the  first  intention  can  be  obtained,  it 
is  quite  out  of  place  in  suppurating  wounds,  when  liga- 
tures arc  applied  for  controlling  secondary  hemorrhage. 

Punctured  wounds,  made  by  the  bayonet  or  sa- 
bre, require  similar  treatment  to  gunshot  wounds.  If 
the  history  and  appearances  clearly  indicate  the  char- 


SABRK    AND    BAYONET    WOUNDS.  213 

acter  of  bho  wound,  there  will  be  no  need  Of  probing 
for  imaginary  foreign  bodies.  Such  wounds  usually 
bleed  more  freely  than  gunshot  wounds,  but  the  hem- 
orrhage is  susceptible  of  control  by  similar  means. — 
pressure  being  preferred  to  ligation  of  arteries.  The 
treatment  should  be  cold  water  dressings — irrigation 
preferred.  Protect  the  wound  from  air,  if  possible,  by 
covering  it  with  adhesive  plaster  or  collodion,  and 
llres&  it  as  seldom  as  possible,  compatible  u-ith  cleanliness. 
Once  probing  of  such  a  wound  should  satisfy  the  curi- 
osity of  any  surgeon.  A  frequent  repetition  of  this 
meddlesome  surgery,  besides  the  needless  pain  inflict- 
ed upon  the  wounded  man,  must  end  in  mischief. 

Simple  incised  wounds,  as  sabre  cuts,  will  be  closed 
by  adhesive  plaster  (or  sutures,  which  are  preferable, 
should  there  be  any  tendency  to  gaping),  to  be  follow- 
ed by  the  cold  water  dressing.  Should  the  wound  be 
not  of  a  serious  character,  it  may  be  left  even  without 
after-dressing — the  little  oozing  from  its  edges,  when 
drawn  together  by  straps  or  sutures,  dries  into  a  scab 
along  the  line  of  wound,  and  excludes  air  with  its  per- 
nicious influences.  This  permits  of  the  remodelling 
process,  and  cicatrization  is  effected  without  suppu- 
ration. 

Should  a  bayonet  or  sabre  wound  transfix  one  of 
the  natural  cavities,  the  internal  injury  ma}'  be  rapid- 
ly fatal  from  hemorrhage,  or  the  injury  inflicted  upon 
the  contained  organs  may,  sooner  or  later,  lead  to  the 
destruction  of  the  patient  by  visceral  inflammation. 
Under  ordinary  conditions,  when  such  wounds  ex- 
ist in  the  extremities,  where  no  large  vessels  are  im- 
plicated, they  require  no  special  treatment.  It  is  a 
class  of  wounds  not  as  frequently  met  with  in  military 
Surgery  as  one  would  suppose.  The  Babre-baypnet, 
when  plunged  into  the  body  among  the  viscera,  leaves 


214  PKOORKSS    OF    GUNSHOT     WOUNDS. 

i 

but  little  work  for  the  surgeon.  Such  cases  seldom 
leave  the  battle-field  alive. 

When  the  ordinary  bayonet  has  buried  itself  deeply 
in  a  limb,  suppuration  may  appear  in  the  course  of*  the 
wound.  Should  pus  be  suspected,  and  fears  exist  that 
it  may  be  pent  up  under  a  fascia,  it  would  be  necessary 
to  dilate  the  wound  to  permit  of  its  free  escape.  Un- 
der no  other  condition  should  a  punctured  wound, 
made  by  either  sword  or  bayonet,  be  dilated,  except 
to  remove  foreign  bodies  or  to  control  serious  hemor- 
rhage, where  it  is  necessary  to  ligate  the  open  mouths 
of  the  bleeding  vessel. 

In  gunshot  wounds  the  swelling  of  the  soft  parts, 
which  commences  a  few  hours  after  the  injury  has  been 
received,  usually  continues  to  increase  until  the  com- 
pletion of  the  fourth  day,  when  it  has  attained  its 
acme,  with  commencing  suppuration.  Should  slough- 
ing occur,  it  will  show  itself  by  the  sixth  or  seventh. 
On  the  eighth  or  ninth  day  the  slough  has,  in  most 
cases,  separated  itself  from  the  edges  of  the  track  of 
the  ball,  and  in  a  few  days  more  will  have  been  disen- 
gaged. With  the  cleansing  of  the  wound,  when  no 
complication  with  foreign  bodies  exist,  the  inflamma- 
tion gradually  subsides,  the  swelling  diminishes,  puru- 
lent discharge  lessens  in  quantity,  and  the'wound  com- 
mences to  contract.  The  middle  portion  of  the  track 
first  closes,  and  with  it  most  frequently  the  opening  of 
exit,  leaving  a  funnel-shaped  canal,  which  diminishes 
from  day  to  day,* becoming  more  superficial,  until  no 
depth  is  left  to  the  orifice  of  entrance.  The  wound 
cicatrizes  with  a  depression,  marking  distinctly  the 
nature  of  the  injury  which  has  been  received.  In  the 
experience  of  many  army  surgeons  the  most  depend- 
ant orifice  heals  last,  without  reference  to  the  entrance 
or  exit  of  the  ball.     Should  the  orifices,  however,  be 


OENERAL    TREATMENT    OF    GUNSHOT    WOUNDS.       215 

situate  in  the  samo  place,  the  orifice  of  exit  is  usually 
tho  first  to  close.  This  is  the  ordinary  course  which 
gunshot  wounds  take  when  judiciously  treated  in  good 
constitutions. 

In  the  general  treatment  of  gunshot  wounds,  interfere 
with  the  general  health  as  little  as  possible.  The 
commonly  prescribed  antiphlogistic  remedies  are,  with 
but  rare  exceptions,  not  required.  The  endless  list  of 
emetics,  purgatives,  diuretics,  and  diaphoretics,  to 
which  somo  European  writers  still  cling  with  wonder- 
ful tenacity,  can,  with  decided  benefit,  be  dispensed 
with. 

Guthrie,  who  represents  this  class,  in  speaking  of 
the  inflamed  stage  of  gunshot  wounds,  says  that  tho 
treatment  for  subduing  this  should  be  active  :  "The  pa- 
tient, if  robust,  ought  to  be  bled  (if  no  endemic  disease 
prevails),  vomited,  purged,  kept  in  the  recumbent  po- 
sition, and  cold  applied  as  long  as  it  shall  be  found 
agreeable  to  his  feelings ;  when  that  ceases  to  be  the 
case,  warm  fomentations  ought  to  be  resorted  to,  but 
they  are  to  be  abandoned  the  instant  the  inflamma- 
tion is  subdued  and  suppuration  well  established." 

The  experience  of  Confederate  army  surgeons  is  de- 
cidedly averse  to  the  use  of  any  depleting  agent.  Ac- 
tive purging  and  vomiting  is  incompatible  with  that 
degree  of  quiet  which  we  have  laid  down  as  a  funda- 
mental rule  in  the  treatment  of  gunshot  wounds.  As 
suppuration  is  usually  long  continued,  and  debility, 
with  a  certain  degree  of  emaciation,  usually  accom- 
panies the  progress  of  gunshot  wounds,  the  disposi- 
tion should  rather  be  to  harbor  strength  in  order  to 
support  this  drain,  than  to  despoil  the  system.  The 
modem  practice  of  support  rather  than  depletion  hastens 
convalescence,  and  is  the  only  rational  practice. 

tieneral  and  local  bloodletting  are  so  soldom  requir- 


lilG      GENERAL   TREATMENT    OF   GUNSHOT    WOUNDS. 

cd  in  the  treatment  of  gunshot  wounds,  the  patient 
having,  in  most  cases,  lost  more  blood  than  the  sys 
tern  could  conveniently  spare,  that  we  need  not  lose 
time  by  discussing  these  remedies  as  formerly  used  in 
the  treatment  of  all  diseases  and  injuries.  Suffice  it 
to  say,  that  in  military  surgery  we  are  rat  called  upon 
to  use  either  of  them  for  the  successful  treatment  of 
gunshot  wounds. 

Kinetics,  as  such,  are  never  required  in  the  general 
treatment  of  wounds.  When  very  small  doses  of  the 
emetic  preparations  are  given,  they  may  bo  useful  in 
inducing  relaxation  and  for  generalizing  the  circula- 
tion, in  this  way  deriving  the  excess  of  blood  from  the 
wound.  Small  doses  of  tartar  emetic  may,  with  other 
remedies,  form  a  good  proscription  in  cases  of  exces- 
sive reaction. 

Mild  purgatives  aro  in  constant  rerpiisition,  both  for 
their  detergent  as  well  as  derivative  effects,  and  may 
be  needed  during  the  treatment  of  nearly  every  case 
of  gunshot  wound.  The  most  commonly  prescribed 
article  is  the  compound  cathartic  pill  of  the  pharma- 
copoeia, although  from  tho  large  list  of  mild  purgatives 
ample  opportunity  is  afforded  for  making  a  selection. 
As  a  rule,  where  the  object  of  the  purgative  is  simply 
to  evacuate  the  bowels,  without  reference  to  exciting 
the  secretion  of  any  of  the  abdominal  organs,  I  have 
always  found  that  an  enema  which  will  act  directly 
upon  the  rectum,  causing  it  to  discharge  its  contents, 
will  give  all  the  comfort  desired.  By  its  use  we  avoid 
the  delay  accompanying  the  administration  of  medi- 
cines, and  the  gastric  disturbance  always  induced  by 
their  irritating  effect  while  passing  through  thirty 
feet  of  intestine,  before  the  desired  evacuation  can  be 
produced.  As  it  is  always  desirable  in  the  treatment 
of  wounds  to  impair  the  digestion  as  little  as  possible, 


GENERAL   TREATMENT   OF   GUNSHOT    WOUNDS.      217 

the  enema,  whether  of  simple  water,  cold  or  warm, 
or  whether  made  more  irritating  by  medication  with 
table  salt,  cpsom  salts,  soap-suds,  etc.,  etc.,  will  al- 
ways be  found  a  valuable  substitute  for  purgative 
medicines. 

The  granulations  of  a  wound  are  said  to  be  a  better 
index  of  the  condition  of  the  intestinal  canal  than  the 
tongue,  as  they  arc  much  more  readily  influenced  by 
any  cause  which  induces  an  irritable  condition  of  the 
system.  Keeping  watch  over  the  digestive  organs, 
preventing,  by  proper  diet,  any  indigestible  food  from 
getting  into  them,  while  the  excretions  which  empty 
into  this  great  sewer  are  not  allowed  to  remain  and 
disturb  the  system,  will  be  at  all  times  judicious  prac- 
tice. 

Diaphoretics  and  diuretics  are  the  milder  antiphlo- 
gistic and  derivative  remedies,  which  may  frequently 
be  required  to  quiet  the  pulse  and  equalize  the  cir- 
culation. 

The  ordinary  febrile  reaction,  which  so  frequently 
follows  the  receipt  of  severe  injury,  should  give  the 
surgeon  no  annoyance  per  se.  It  is  only  a  symptom  — 
an  indication  of  the  extent  of  sympathy  between  the 
local  irritation  and  the  system  at  largo.  When,  by 
judicious  local  treatment,  the  nervous  excitement 
near  the  wound  subsides,  the  pulse  will  pari  passu 
lose  its  frequency  and  irritability.  It  is  not  a  disease 
within  itself,  requiring  to  be  especially  treated. 

In  the  general  treatment  of  wounds,  diet  and  rest 
are  the  two  great  remedies  which,  in  by  far  the  ma- 
jority of  wounds,  even  the  most  serious,  are  all  (hat 
is  required  for  successful  treatment.  Should  there  bo 
an  excess  of  general  excitement,  which  a  purge  with 
a  diaphoretic  or  diuretic  is  not  able  to  quiet,  Ave 
would  administer  to  such  ono  of  that  class  of  modi- 
s 


218      GENERAL   TREATMENT   OF   GUNSHOT    WOUNDS. 

cincs  which  is  known  to  control  the  excitement  of  tho 
circulation,  quiet  tho,  brain,  and  act  as  a  sedative 
upon  the  nervous  system  generally,  viz:  opium,  hyos- 
cyamus,  eonium,  belladonna,  digitalis,  veratrura  viride, 
gelseminum  sempervirens,  etc. 

When  local  reaction  is  excessive,  with  great  swell- 
ing and  heat,  there  is  a  class  of  general  remedies 
which  might  be  given  with  advantage.  They  act  by 
increasing  the  tone  of  blood-vessels,  and  thereby 
cause  a  contraction  in  their  walls  and  diminution  of 
their  calibre.  This  curtails  necessarily  the  amount 
of  blood  flowing  through  these  temporarily  diminished 
vessels, and  therefore  relieves  congestions.  Upon  such 
remedies  much  reliance  might  be  placed.  Holding  a 
conspicuous  position  among  these  are  the  mur.  tinct. 
of  iron,  tinct.  of  belladonna,  wine  of  ergot,  etc.  It 
is  by  contracting  the  blood-vessels  to  such  an  oxtent 
that  a  sufficient  supply  of  blood  can  not  be  transmit- 
ted for  the  nourishment  of  distant  tissues,  that  morti- 
fication follows  the  too  liberal  and  long-continued  use 
of  ergot.  By  this  property  of  producing  contraction 
in  blood-vessels  uterine  hemorrhages  are  checked,  or 
the  action  of  the  gravid  womb,  with  its  immensely 
developed  blood-vessels,  excited.  The  entire  profes- 
sion have  adopted  the  mur.  tinct.  of  iron  as  Dearly  a 
specific  against  the  fearful  inflammatory  reaction  of 
erysipelas,  in  which  disease  it  causes  a  rapid  and  per- 
manent contraction  of  the  distended  capillary  vessels 
involved.  For  stronger  reasons,  it  is  equally  etficacious 
in  simple  inflammatory  engorgements.  Belladonna 
shows  its  general  action  by  dilating  the  pupil — an 
effect  explained  by  the  change  in  the  circulation  of 
tho  blood-vessels  of  the  iris.  Its  advantages  in  re- 
lieving injection  of  the  blood-vessels  of  the  eye  are 
well  known  and  largely  used.     It  is  spoken  of  as  tho 


GENERAL   TREATMENT   OP   GUNSHOT    WOUNDS.      219 

remedy  for  the  rapid  relief  of  congestion  of  the  spinal 
cord.  Although  these  are  tho  individual  effects  of 
such  remedies,  the}r  aro  not  the  specific  action  of 
these  medicines.  Their  influence  belongs  to  the  econ- 
omy; and  in  affecting  all  the  tissues,  those  feel  their 
influence  most  which  arc  offending,  as  there  would  bo 
the  widest  field  for  the  remedy  to  show  its  common 
effects. 

Inflammation  is  a  perverted  condition  of  tho  blood 
and  blood-vessels  of  a  part,  which  means  a  modified 
state  of  nutrition.  Whenever  a  cause  of  local  irrita- 
tion exists,  which  creates  a  disturbing  influence  in  the 
economy  and  depresses  the  vitality  of  a  part,  nature, 
ever  on  the  alert  to  ward  off  evil,  pours  its  pabulum 
of  life  into  the  injured  portion,  to  counteract  tho  per- 
nicious effects  of  the  injury.  The  depressing  effects 
upon  the  nerves  permit  the  relaxation  of  the  blood- 
vessels and  invite  in  the  circulating  fluid.  The 
blood  flows  in,  filling  up  all  of  the  channels  and  inter- 
rupting the  healthy  circulation  through  the  part,  and 
by  its  accumulation  produces  still  further  depression. 

There  arc  two  diametrically  opposed  means  of  cor- 
recting this  condition  and  restoring  health.  One  is, 
by  reducing  the  amount  of  blood  carried  to  the  part 
which  threatens  to  overwhelm  the  vital  functions  of 
Bach  an  inflamed  portion  of  the  body.  This  is  effect- 
ed by  bloodletting,  vomiting,  purgation,  abstemious 
diet,  and  the  entire  list  of  depletory  or  spoliative 
remedies,  which  weaken  the  enemy  to  such  an  extent 
as  to  allow  of  the  part  attacked  successfully  coping 
with  tin-  disease.  But  when  the  disease  is  conquered, 
tin-  victory  may  l>c  as  disastrous  as  a  defeat,  a  Long, 
tedi'ius  convalescence  being  required  to  restore  tho 
patient  to  Ins  former  Mate  of  health.  Experience  has 
shown  this  destructive  plan  of  treatment  to  bo  inju- 


220      GENERAL   TREAT MKNT   OF   GUNSHOT    WOUNDS. 

rious,  and  it  lias  been,  therefore,  properly  discarded 
for  a  much  more  preferable  method.  This  consists  in 
increasing  the  tone,  both  of  part  and  system,  by  sup- 
porting agents,  which  strengthen  the  garrison,  in- 
crease the  vital  powers  residing  within  the  tissues  fof 
resisting  the  encroachments  of  disease,  and  thus  are 
enabled  to  drive  out  the  enemy,  however  violently 
the  attack  may  be  made.  These  successes  are  at- 
tained with  but  little  loss  on  the  part  of  the  system, 
which  comes  out  of  the  fire  unscathed.  Our  object, 
then,  should  always  be  to  cure  disease  by  using  such 
remedies  as  will  cause  the  least  possible  loss  to  the 
economy. 

We  have,  therefore,  abandoned  the  plan  of  starving 
wounded  men.  or,  by  the  mistaken  policy  of  a  rigor- 
ous diet,  to  keep  oft'  inflammation.  We  look  upon 
inflammation  as  always  depressing  in  its  character — 
nature  requiring  assistance  from  without  to  enable 
her  to  cope  successfully  with  disease.  We  do  not 
hesitate,  therefore,  as  soon  as  the  stage  of  reaction 
has  passed,  to  feed  the  wounded  with  strong,  nour- 
ishing diet,  and  also  further  to  support  the  system 
by  the  use  of  stimuli.  Whiskey  has  been  freely  given 
to  our  wounded,  particularly  during  the  suppurative 
stage,  and  with  decided  benefit.  As  the  irregularities 
of  camp  life,  especially  during  an  active  campaign, 
have  a  depressing  effect  upon  all  soldiers,  which,  al- 
though not  apparent  as  lorn;-  as  they  are  capable  of 
performing  duty,  shows  its  influence  immediately 
when  they  are  placed  upon  the  sick-list,  the  above 
course  of  supporting  treatment  is  particularly  appli- 
cable to  the  wounded  of  armies. 

In  all  injuries,  were  it  not  for  an  exquisitely  sensitive 
nervous  system,  we  would  have  but  little  systemic 
sympathy,  and,  therefore,  but  little  personal  annoy- 


OPIUM    IN    GUNSHOT    WOUNDS.  221 

ance.  In  the  inferior  animals,  where  the  sensibilities 
are  of  a  low  description,  and  where  the  various  por- 
tions of  the  body  are  more  or  less  isolated  and  not 
tied  together  by  numerous  cords  of  nervous  sympa- 
thy s,  limbs  can  be  torn  off  without  deleterious  effect 
upon  the  rest  of  the  body,  and  without  producing  in- 
flammation. These  inflammatory  tendencies  are  only 
observed  as  we  advance  in  the  scale  of  animal  life, 
until  we  find  in  man  a  perfection  of  a  nervous  system, 
with  its  corresponding  sympathies  and  susceptibilities 
to  physiological  as  well  as  pathological  impressions. 
If  we  could,  by  some  metamorphosis  in  the  nervous 
sympathies  of  man,  temporarily  establish  a  condition 
simulating  the  more  primitive  developments,  Ave  would 
diminish  the  dangers  of  local  trouble;  or  if  we  could 
take  possession,  as  it  wrere,  of  the  nervous  functions, 
and  reduce  them  to  their  lowest  stage  for  extending 
sympathies,  we  could  equally  keep  down  irritation, 
and,  to  a  great  extent,  jugulate  the  tendency  to  con- 
gestion, and,  subsequently,  inflammation. 

Opium,  by  which  we  can  effect  this  subjection,  will 
ever  be  the  greatest  boon  to  the  military  surgeon.  It 
allays  both  local  and  general  irritation,  annuls  pain, 
soothes  the  mind,  blunts  the  sensibility  of  the  injured 
nerves,  and  quiets  the  tumultuous  action  of  the  heart. 
By  its  sedative  influence  upon  the  cerebrospinal  sys- 
tem it  allows  the  sympathetic  system  of  nerves  to 
act  in  unrestrained  vigor,  and  through  it  tone  is  re- 
stored to  the  muscular  walls  of  blood-vessels.  Under 
its  influence  there  is  no  longer  a  local  irritation  in- 
ducing blood  to  the  part,  nor  dilated  and  relaxed 
blood-vessels,  permitting  an  increased  flow  of  blood; 
and  the  result  i^  that  inflammation,  which  is  inti- 
mately cpnnected  with  a  local  congestion  and  a  local 
irritation,   is  kept    in    abeyance.     It    is,  therefore,   a 


222         ENDERMIC  USE  OF  MORPHINE. 

remedy  which  should  never  be  absent  from  our  reach. 
Going  on  the  field,  the  surgeon  should  have  bis  haver- 
Back  -well  stored  with  it  for  immediate  use;  and 
throughout  the  entire  treatment  of  the  wounded  it 
will  ever  hold  a  conspicuous  place.  Of  all  the  pre- 
parations of  opium,  morphine  is,  perhaps,  the  best 
article  for  wounded  men,  as  it  has  lost  in  preparation 
some  of  those  astringent  properties  which,  as  opium 
or  laudanum,  would  produce  too  great  a  tendency  to 
constipation. 

The  endermic  method  of  using  this  remedy  would 
prevent  endless  suffering  on  the  battle-field  or  in  hos- 
pital practice.  When  morphine  is  taken  into  the 
stomach,  it  is  dissolved  in  the  fluids  there  found,  and 
then  undergoes  absorption.  This  takes  place  with 
greater  or  less  rapidity,  according  to  the  nervous  ex- 
citement under  which  the  system  is  laboring.  At 
times  its  absorption  is  very  slow,  and  its  effects  upon 
the  system,  from  the  small  quantity  found  in  the 
circulation  at  any  one  time,  very  indifferent.  Under 
other  circumstances,  when  the  absorbents  of  tho 
stomach  arc  apparently  in  a  condition  of  tempo- 
rary paralysis,  with  complete  suspension  of  their 
function,  very  largo  doses  are  administered  in  vain 
to  produce  the  soothing  effects  which  naturally  be- 
long to  the  drug.  It  remains,  perhaps,  unchanged  in 
the  stomach.  Under  the  same  condition,  if  a  much; 
smaller  dose,  in  solution,  be  injected  under  the  skin  of 
any  portion  of  the  body,  the  vessels  seem  to  absorb 
immediately  the  fluid,  and  its  full  effects  are  obtained 
in  a  few  minutes.  The  following  cases  will  show  tho 
marked  efficacy  of  the  remedy  when  used  l^-poder- 
mically : 

Mrs.  C.  had  been  operated  upon  for  cataract  by 
division   of  the  lens.      Violent  inflammation  ensued, 


ENDERMIC   USE   OP    MORPHINE.  223 

ending  in  the  destruction  of  the  eye,  and  for  three  days 
she  sufferod  agony.  Day  and  night  she  rolled  about 
the  bed  in  ceaseless  torment,  in  spite  of  repeated  doses 
of  morphine.  Finding  that  one-half  grain  every  two 
or  three  hours  produced  no  alleviation  of  her  suffer- 
ing, I  tried  the  experiment  of  injecting  one-third  of 
a  grain,  dissolved  in  two  minims  of  water,  under 
the  skin  covering  the  sternum.  A  Wood's  endermic 
syringe  was  used.  Absorption  was  immediate  :  in  two 
minutes  she  was  relieved;  in  five,  all  pain  had  dis- 
appeared, and  in  ten  minutes  from  the  timo  of  the 
injection  she  was  sleeping  soundly,  after  seventy  hours 
of  unmitigated  torture. 

Mr.  T.  had  been  suffering  with  articular  inflamma- 
tion of  the  right  elbow  joint,  and  for  three  weeks  had 
suffered  so  severely  as  to  be  robbed  of  all  rest.  He 
visited  Charleston,  four  hundred  miles  from  his  home, 
to  seek  relief.  An  injection  of  one-third  grain  relieved 
him  of  all  pain  in  five  minutes.  After  twelve  hours' 
sleep  he  awoke  much  refreshed  ;  and  although  a  gen- 
eral soreness  continued  for  some  days,  no  acute  pain 
was  felt  in  the  elbow  from  the  time  of  injection. 

Captain  M.  was  accidental^  shot  in  the  neck  with  a 
Colt's  pocket  revolver.  His  head  being  turned,  tho 
ball  entered  the  skin  over  the  larynx,  coursed  down- 
ward and  backward  through  the  posterior  triangle  of 
tlic  neck,  and  was  found  under  the  skin  of  the  shoulder 
over  the  spine  of  the  scapula,  and  was  removed.  Con- 
siih-rable  swelling  and  extravasation  followed,  which, 
diffusing  itself,  discolored  that  side  of  the  neck.  Some 
branches  of  the  brachial  plexus  of  nerves  must  have 
been  injured  by  the  ball,  as  the  patient  was  seized  with 
violent  pains  shooting  down  the  arm  toward  the  fin- 
gers, ami  which,  although  never  altogether  absent, 
would  increase  to  torture  as  evening  advanced.     Tow- 


224  ENDERMIC    USE   OF    MOBPIIINE. 

arc!  morning  they  would  remit  and  allow  of  sleep, 
after  a  restless  and  painful  night.  Gum  opium  and 
morphine,  in  large  doses,  gave  him  no  relief.  The 
arm  was  so  sensitive  that  he  would  not  permit  its 
being  handled.  One-fourth  of  a  grain  of  morphine, 
in  three  or  four  drops  of  water,  was  injected  under 
the  skin  of  the  shoulder;  in  five  minutes  all  pain  had 
left  him,  and  his  arm  could  he  examined  rudely  with- 
out the  slightest  suffering. 

Although  other  eases  of  gunshot  wounds  could  be 
detailed  in  which  the  endermic  use  of  morphine  gave 
immediate  and  entire  relief  from  pain,  the  above  re- 
cital will  suffice  as  proof  of  its  decided  usefulness. 

By  the  use  of  this  simple  process,  a  new  and  exten- 
sive field  for  doing  good  is  open  to  the  humane  mili- 
tary surgeon,  and  he  who  is  the  fortunate  possessor  of 
this  talisman  will  receive  daily  the  thanks  and  bless- 
ings of  his  suffering  patients.  When  chloroform  can 
not  be  obtained,  I  would  suggest  this  mode  of  blunt- 
ing sensibility,  immediately  before  operations  are  per- 
formed or  painful  and  tedious  dressings  are  made.  It 
will  bo  found  a  good  substitute, and  one  which  will  yield 
its  full  effects  without  delay  or  trouble.  There  are 
very  few  injuries  requiring  operation  which  do  not 
demand  the  free  use  of  opium.  Narcotizing  the  pa- 
tient immediately  before  the  operation,  and  keeping 
him  under  its  influence  for  some  hours,  is  among  the 
best  means  of  preventing  an  excess  of  reaction.  The 
rapidit}'  of  action  when  morphine  is  used  endermi- 
cally  is  a  very  great  advantage  on  the  field,  where 
every  moment  is  of  value.  For  complete  narcotism, 
where  a  sufficient  quantity  of  morphine  is  used,  five 
minutes  are  all  that  is  required;  while  with  chloro- 
form we  all  know  that,  when  under  excitement,  its 
inhalation  is  often  extended  to  from  twenty  to  thirty 


ENDERMIC    USE    OF    MORPHINE.  225 

minutes,  and  even  longer — time  which  the  surgeon  in 
the  field  can  not  well  sparo.  Judging  from  analogy,  I 
should  say  that,  under  the  narcotizing  influence  of 
morphine,  operations  should  bo  much  more  successful 
than  under  chloroform — as  the  impression  is  more 
lasting,  and  the  inflammatory  sequela)  ought  to  be 
correspondingly  in  abeyance. 


CHAPTER  VII. 

Complications  which  arise  dubing  the  treatment  of  Gunshot 
Wounds — Erysipelas,  contagious  and  infectious  character — 
Constant  tkndency  to  Debility — Treatment,  General  and  Lo- 
cal— Hospital  Gangrene;  its  appearances;  how  recognized; 
Causes  giving  rise  to  it — Thorough  Ventilation  necessary  to 
successful  treatment — local  applications,  actual  cauteby, 
etc, — Pyemia  a  rare  disease  in  our  country;  symptoms — The- 
ory of  Multiplied  Abscesses — Great  remedy;  Prevention  by 
rigid  observance  of  hygienic  regulations — local  and  gener- 
AL Treatment — Tetanus,  characters;  March — Rarity  of  curb 
in  Military  Surgery — Local  and  General  treatment  upon 
which  most  reliance  can  be  placed — Woorara  in  Tetanus — 
Hectic,  from  long-continued  suppuration — Permanent  and 
Periodic  Pains. 

Erysipelas. — We  have  already  examined,  in  detail, 
the  causes  of  secondary  hemorrhage,  which  is  one 
of  the  most  alarming  complications  that  can  befall 
the  wounded.  A  second,  which  is  equal  I  jr  alarming 
to  both  surgeon  and  patient,  is  erysipelas.  This  dis- 
ease appears  to  revel  in  tho  depressing  influences 
which  follow  armies,  and  sometimes,  as  an  epidemic, 
attacks  all  wounds,  ravages  limbs,  and  makes  a  fright^ 
fill  list  of  victims.  Although  it  frequently  occurs  as 
an  idiopathic  disease,  its  most  common  exciting  cause 
in  military  hospitals  is  a  wound. 

Idiopathic  erysipelas,  which  is  often  mot  with  in 
isolated  cases,  and  usually  found  attacking  persons 
without  wounds,  is  a  diffused  inflammation  of  the 
skin,  most  frequently  seated  upon  the  face,  although  it 
may  show  itself  upon  any  portion  of  tho  body.    A  red, 


TRAUMATIC    ERYSIPELAS.  227 

swollen,  glistening  spot,  accompanied  by  a  sensation 
of  heat,  weight,  and  fullness,  seems  to  encroach  rapid- 
ly upon  the  contiguous  surface,  nearly  visibly  extending 
its  outline.  Its  appearance  may  have  been  preceded 
by  a  chill,  which  is  followed  by  lassitude,  pain  in  the 
limbs,  back,  and  head,  quick  pulse  and  furred  tongue, 
loss  of  appetite,  and  nausea,  often  with  vomiting. 
During  the  secondary,  in  the  simple  form  of  the  dis- 
ease, a  moderate  effusion  of  serum  escapes  into  the 
subcutaneous  tissue.  Where  this  tissue  is  loose,  as 
about  the  eyelids,  the  swelling  from  serous  effusion  be- 
comes excessive.  The  limit  of  the  redness  is  at  times 
well  defined,  although  usually  it  is  gradually  lost  in 
the  surrounding  healthy  tissue.  After  a  continuance 
of  a  few  days,  if  its  tendency  to  spread  is  controlled 
by  judicious  treatment,  numerous  vesicles,  containing 
a  clear  serum,  appear  upon  the  reddened  surface,  and 
are  considered  an  indication  of  returning  health.  These 
burst,  the  fluid  dries  up,  the  skin  flakes  off,  and  with 
these  phenomena  the  general  symptoms  gradually 
subside. 

Gunshot  wounds  in  patients  debilitated  by  the  many 
depressing  influences  of  camp  life,  are  peculiarly  prone 
to  attacks  of  erysipelas.  The  variety  most  frequently 
met  with  among  such  is  the  phlegmonous,  or,  as  it  is 
now  called,  the  cellule-cutaneous  variety.  After  a  pre- 
monitory chill  it  makes  its  appearance  with  violent 
inflammatory  symptoms,  intense  swelling,  tension, 
redness,  pain,  heat,  and  effusion,  the  affected  part 
pitting  on  pressure.  It  extends  rapidly  from  the 
wound  as  a  centre,  and  soon  covers  a  large  area,  ac- 
companied by  symptoms  of  inflammatory  n-ww  with 
a  dirty,  foul  tongue,  and  deranged  gastrointestinal 
secretion,  generally  constipation,  although  at  times 
diarrhoea,  the   urine  being  scanty,  high-colored,  and 


228  KFFECTS    OF    ERYSIPELAS. 

acrid.     It  will  be  remarked  that  the  pulse,  although 
frequent  and  full,  has  no  strength  ;  and  general  pn 
tration   ensues  at  a  very  early  day.     Often   by   the 
fourth   day   the   hardened   edematous   tissue   in  the 

neighborhood  of  the  wound,  although  it  is  still  highly 
colored,  presenting  a  glistening  appearance,  already 
feels  boggy  when  the  fingers  are  pressed  upon  it,  in- 
dicating the  extensive  formation  of  pus  and  sloughs 
under  the  skin.  The  wound  usually  gives  outlet  to 
these  pent-up  secretions. 

As  the  disposition  of  the  disease  is  not  to  localize 
itself,  the  effusion  actively  thrown  out  in  the  extent  of 
tissues  undergoes  a  conversion  into  pus,  which  leaves 
this  matter  disseminated  in  all  the  tissues  where  the 
effusion  had  taken  place.  It  is  in  this  manner  that 
the  extensive  purulent  dissection  of  limbs  occurs;  by 
which  muscles  are  isolated,  blood-vessels  separated 
from  the  surrounding  connections,  bones  exposed  from 
their  periosteum,  joints  opened,  and  with  these  a  gen- 
eral destruction  of  cellular  tissue,  which  may  be  pulled 
out  from  the  wound  in  shreds  or  layers  resembling 
strips  of  wet  chamois  leather.  The  extensive  loss  of 
support  to  the  skin  from  the  undermining  and  destruc- 
tion of  the  subcutaneous  tissues  causes  it  to  breakdown 
into  sloughs,  which  make  an  opening  for  the  escape  of 
this  accumulating  fluid.  Nature  in  its  weakened  con- 
dition can  not  stand  this  drain  of  its  best  nutrient 
material ;  and  prostration,  feeble,  irregular  pulse,  dry 
tongue,  diarrhoea,  delirium,  and  finally  coma,  ends  the 
scene.  Or,  .should  judicious  treatment  check  its  in- 
roads, a  tedious  convalescence  and  a  shattered  consti- 
tution remain  to  the  patient. 

Erysipelas  can  always  be  recognized  by  its  distinc- 
tive characters  of  widely  extended  local  inflammation, 
with  tendency  to  the  rapid  suppuration  and  sloughing 
of  the  wound. 


PROPAGATION    OF   ERYSIPELAS.  22JJ 

The  prognosis  of  this  complication,  in  military  sur- 
gery, is  always  serious,  when  it  occurs  after  gunshot 
wounds,  as  the  constitutions  of  the  patients  have  been 
undermined  to  a  certain  extent  by  the  hardships  and 
irregularities  to  which  all  soldiers  in  time  of  war 
must  submit. 

In  the  treatment  of  gunshot  wounds  it  must  be  re- 
membered that  erysipelas,  which  is  a  very  serious 
complication,  is  often  produced  by  a  careless  disregard 
of  those  hygienic  regulations  which  are  so  essential 
in  the  proper  organization  of  a  hospital.  Over-crowd- 
ing, bad  ventilation,  and  a  want  of  cleanliness — a  com- 
bination which  produces  a  poisoned  atmosphere — are 
frequent  causes  for  its  production  and  propagation;  al- 
though it  can  not  alwaj's  be  traced  to  the  depressing 
effect  of  bad  food  or  a  vitiated  atmosphere,  as  cases  occur 
in  private  quarters  where  ventilation  is  perfect.  As  the 
disease  is  clearly  contagious  as  well  as  infectious,  the 
directors  of  military  hospitals  must  be  very  careful 
how  they  permit  a  case  of  er3rsipelas  to  be  introduced 
int<>  a  ward  with  wounded  men — for  inoculation  will 
at  once  ensue;  and  when  eiysipelas  has  taken  posses- 
sion of  a  ward,  it  is  with  great  difficulty  eradicated. 
Its  effects  can  be  traced  first  upon  contiguous  patients, 
whose  wounds,  healing  kindly  prior  to  the  introduc- 
tion of  this  focus  of  contamination,  now  take  on  erysi- 
pelas. The  system  soon  shows  the  depression  under 
which  the  patient  is  laboring.  Some  further  compli- 
cation, with  low  visceral  inflammation  of  either  the 
membranes  of  the  brain  or  lungs  or  intestinal  surface 
ensues,  and   life  is  overwhelmed  bj'  this  combination. 

Brichsen,  in  his  Science  and  Art  of  Surgery,  men- 
tions the  following  case  in  proof  of  the  contagion  of 
erysipelas,  as  having  occurred  in  one'of  his  wards  at 
University  Collego  hospital  :  "  The  hospital  had  been 


-230  TREATMENT   OF   ERYSIPELAS. 

free  from  any  cases  of  this  kind  for  ti  considerable 
time,  when,  on  the  16th  of  January,  1851,  at  aboul 
noon,  a  man  was  admitted  under  my  care  with  gan- 
grenous  erysipelas  of  the  legs,  and  placed  in  the  ward. 
On  my  visit,  two  hours  after  Ids  admission,  I  ordered 

him  removed  to  a  separate  room,  ami  directed  the 
chlorides  to  be  freely  used  in  the  ward  from  which  he 
had  hcen  taken.  Notwithstanding  these  precautions, 
however,  two  days  after  this  a  patient,  from  whom  a 
portion  of  necrosed  ilium  had  been  removed  a  few 
week's  previously,  and  who  was  lying  in  the  adjoining 
bed  to  that  in  winch  the  patient  with  the  erysipelas 
had  been  temporarily  placed,  was  seized  with  erysipe- 
las, of  which  he  speedily  died.  The  disease  then 
spread  to  almost  every  case  in  the  ward,  and  proved 
fatal  to  several  patients  who  had  been  recently  oper- 
ated upon."  If  such  he  its  tendency  in  civil  hospitals, 
how  frightful  is  its  march  among  the  wounded  in 
military  hospitals'.''  Such  cases  should  be  kept  exclu- 
sively to  themselves,  or  they  entail  incalculable  loss 
upon  the  wounded. 

The  antiphlogistic  treatment  of  erysipelas,  especial- 
ly the  phlegmonous  variety  which  we  are  now  con- 
sidering, has  for  many  years  hcen  abandoned;  and  he 
who  attempts  to  cure  erysipelas  in  military  surgery 
h}r  depressing  agents,  will  pay  dearly  for  his  rash- 
ness. However  violent  arc  its  symptoms,  the  surgeon 
must  not  he  deceived.  It  is  a  disease  of  marked  debil- 
ity; the  violence. of  its  inception  is  only  a  mask, 
to  he  thrown  off  in  a  few  days,  and  often  in  a  few 
hours.  When  the  plan  of  attack  is  so  well  known  as 
it  is  in  erysipelas,  where  a  study  of  tin-  natural  histo- 
ry of  the  disease  has  invariably  shown,  in  its  march, 
certain  and  speedy  prostration,  the  surgeon  is  highly 
culpable  who  does  not  commence  with   the  earliest 


TREATMENT   OF   ERYSIPELAS.  231 

treatment  to  build  np  and  Bupport  the  sj'stem,  and 
thus  prepare  it  to  withstand  the  depression  which  is 
so  sure  to  ensue,  and  which,  if  overlooked,  will  lead 
to  such  serious  consequences. 

Prevention  is  always  more  judicious  than  cure,  and, 
therefore,  our  first  care  should  be — by  the  strict  ob- 
servance of  those  hygienic  regulations  for  ventilation 
and  cleanliness,  and  against  over-crowding — to  keep 
the  wards  of  a  hospital  with  so  pure  an  atmosphere 
as  to  give  no  encouragement  for  this  low  class  of  dis- 
eases to  intrude.  When  a  case  appears,  isolate  it  at 
once;  give  it  the  advantage  of  a  large  airy  room 
with  free  ventilation,  or,  what  is  found  still  more  sat- 
isfactory, put  the  patient  in  a  tent  in  which  air  can 
be  freely  admitted,  and  use  every  precaution  against 
contagion.  Tho  use  of  sponges,  bandages,  etc.,  re- 
quired by  such  a  patient,  must  be  restricted  exclu- 
sively to  himself;  for  should  the  same  sponge  .be 
used  by  a  dozen  woHnded  men,  they  would  all  be  as 
surely  inoculated.  Fresh  air  is  indispensable  in  the 
successful  treatment  of  this  disease.  Leave  all  the 
windows  open  for  thorough  ventilation,  even  at  the 
risk  of  catarrhal  affections,  which  arc  trivial  when 
compared  to  the  serious  character  of  the  disease  under 
discussion. 

The  treatment  of  phlegmonous  erysipelas,  ever  hav- 
ing in  view  the  steady,  onward  march  of  the  disease 
to  suppuration,  sloughing,  and  prostration,  unless  a 
barrier  is  thrown  across  its  path,  should  be,  from  the 
commencement,  stimulating  and  supporting.  This 
tonic  course,  which  is  equally  successful  in  simple 
Idiopathic  erysipelas,  is  prefaced  by  some  mild  cathar- 
tic, t"  oleanse  the  bowels  of  imparities  which  rapidly 
accumulate  in  them,  and  to  excite  healthy  secretions 
from    the   digestive   organs      For   this   purpose,  the 


232  TREATMENT  OF   ERYSIPELAS. 

compound  colocynth  pill  would  he  a  good  prescrip- 
tion, although  a  dose  of  castor  oil  or  sulphate  of  mag- 
nesia would,  in  the  majority  of  cases,  fill  every  indi- 

cation.  "Without  waiting  the  action  of  ("his  cathartic, 
from  which  only  a  moderate  effect  is  desired,  we  at 

once  prescribe  what  is  now  called  the  specific  by 
many,  and  recognized  as  useful  hy  all — the  tincture  of 

the  muriate  of  iron,  in  doses  of  from  twenty  to  thirty 
drops,  in  a  wineglass  of  water  every  three  hours. 
Besides  acting  as  a  general  tonic,  and  also,  through 
iis  mineral  acid  upon  the  liver,  promoting  the  biliary 
secretion,  it  appears  to  affect  more  immediately  the 
enfeebled  and  distended  blood-vessels,  producing  a 
permanent  contraction  of  their  muscular  walls  and  a 
diminution  of  their  calibre,  in  this  way  relieving  con- 
gestion, and  preventing,  to  a  great  extent,  effusions. 
I  have  seen  it  cut  short  a  traumatic  erysipelas  of  the 
face,  after  an  extensive  operation  for  cheiloplasty,  in 
thirty-six  hours  from  its  appearance.  The  perchloride 
or  persulphate  of  iron,  in  from  five  to  ten  drop  doses, 
is  preferred  by  some  surgeons,  while  quinine  as  a 
tonic  is  also  found  useful. 

Jn  connection  with  the  mar.  tincture  of  iron,  ami 
of  equal  importance  with  it,  is  the  liberal  use  of  alco- 
holic stimuli  and  nourishing  diet.  Erichsen  says  :  "I 
have  seen  the  best  possible  results  follow  the  frco 
administration  of  the  brandy  and  egg  mixture,  to 
which  I  am  in  the  habit  of  trusting  in  the  majority 
of  these  cases."  Its  liberal  use  will  restore  strength, 
soften  the  tongue,  and  remove  delirium.  When  the 
skin  is  dry  and  harsh,  mild  diaphoretics  should  bo 
used,  and  as  anodynes  are  always  required  in  the 
treatment  to  allay  pain  and  to  give  sleep,  Dovers' 
powders  would  be  a  valuable  agent.  By  adopting 
this  course  of  attending  to  the  secretions,  keeping 


LOCAL   TREATiMENT    OF    ERYSIPELAS.  233 

the  bowels  soluble,  and  by  generous  diet  and  free 
stimulation  supporting  the  system,  even  from  the  very 
commencement,  against  that  prostration  which  is 
certain,  sooner  or  later,  to  show  itself,  this  scourge 
in  military  hospitals  will  be  most  successfully  con- 
trolled. 

Considering  the  disease  as  one  of 'marked  debility, 
most  reliance  should  be  placed  upon  the  general  treat- 
ment. In  the  idiopathic  form  of  the  disease,  the  tinct- 
ure of  the  muriate  of  iron,  with  attention  to  the  diges- 
tive organs,  is  now  considered  quite  sufficient  to  check 
the  disease  without  the  use  of  local  remedies.  The- 
usual  local  treatment  in  simple  erysipelas  consists  in 
painting  the  part  inflamed,  as  well  as  the  contiguous 
healthy  surface,  with  tinct.  iodine,  or  with  a  solution 
of  nitrate  of  silver  (two  drachms  to  one  ounce  of 
water),  or  the  part  is  kept  bathed  in  a  solution  of  sul- 
phate of  iron.  Where  it  shows  a  disposition  to 
spread,  the  healthy  skin  around  the  inflamed  spot  is 
covered  with  a  narrow  strip  of  blister  plaster,  or 
painted  with  a  saturated  solution  of  nitrate  of  silver. 
If  the  cuticle  is  destroyed  by  these  applications,  the 
extension  of  the  disease  is  checked.  All  local  appli- 
cations should  tend  to  relieve  engorgement.  In  the 
early  inflammatory  stage  of  phlegmonous  erysipelas, 
before  suppuration  is  established,  painting  the  limb 
with  the  pcrchloride  of  iron,  or  the  tincture  of  iodine,  or 
using  compresses  soaked  with  tincture  of  arnica,  etc., 
would  tend  to  promote  healthy  action.  Cold  water, 
by  irrigation,  or  iced  applications,  would  be  as  useful 
here  as  in  any  other  engorgements,  although  their  ir- 
regular application,  with  the  sudden  and  frequent 
changes  of  temperature  which  accompany  it,  has 
caused  cold  water  dressings  to  be  accused  of  inducing 
erysipelatous  inflammation.    All  of  these  applications 

T 


234       LOCAL  TREATMENT  OF  EKYSI  I'ELAS. 

may  be  accompanied  with  the  methodically  applied 

roller,  which  will  compress  the  limb,  and,  by  its  me- 
chanical support,  diminish  infiltration  and  congestion, 
and  relieve  tension  and  Bwelling.  Sugar  of  lead 
lotions  arc  highly  lauded.  Five  incisions  are  reconv 
mended  by  many  Burgeons  to  relieve  the  engorged 
vessels.  They  give  great  relief  to  the  patient,  but  it 
is  a  question  whether  they  do  not  increase  the  irrita- 
tion and  hasten  the  suppurative  stage — an  effect  not 
to  be  desired,  as  the  entire  armamentarium  of  the 
surgeon  is  directed  against  the  formation  of  pus. 

When  pus  has  formed  (which  will  be  recognized  by 
the  doughy  condition  of  the  parts,  into  which  the 
fingers  sink  when  pressure  is  made,  and,  a  little  later, 
by  fluctuation),  incisions  should  be  made  sufficiently 
free  to  admit  of  the  ready  escape  of  pus  at  the  same 
time,  parallel  with  the  axis  of  tin-  limit  and  also  with 
the  course  of  the  main  blood-vessels,  so  that  these 
may  be  avoided.  Stimulating  water  dressings  should 
be  continued,  to  hasten  the  elimination  of  the  sloughs 
and  diminish  the  amount  of  secretion.  The  tincture 
of  arnica,  spirits  of  camphor,  Labarraque's  chloride  of 
soda,  diluted  with  from  six  to  ten  parts  of  water, 
diluted  pyroligneous  acid,  diluted  tincture  of  iodine,  or 
the  persulphate  or  percbloride  of  iron,  cither  pure  or. 
diluted,  make  excellent  stimulating  applications,  ex- 
citing healthy  action  in  the  inflamed  part,  and  check- 
ing the  tendency  to  continued  suppuration.  Wherever 
pus  shows  a  disposition  to  hag,  it  should  bo  let  out  hy 
incisions.  As  the  skin,  largely  undermined,  is  liable 
to  slough  extensively,  it  should  he  supported  hy  prop- 
erly applied  bandages,  which,  by  diminishing  the 
cavity  within,  will  prevent  the  burrowing  of  pus,  and 
cause  the  skin  to  adhere  to  the  deeper  parts  as  soon 
as  adhesive  action  can  he  excited. 


HOSPITAL   GANGRENE.        •  235 

Hospital  Gangrene. — Still  another  fatal  complica- 
tion, to  which  gunshot  wounds  arc  liable,  is  hospital 
gangrene — the  name  being  significant  of  the  cause  of 
this  pest,  as  it  is  rarely  seen  as  an  isolated  disease 
without  the  crowded  wards  of  a  hospital.  It  is 
highly  probable  that,  like  the  former  diseases  which 
we  have  just  considered,  it  is  a  blood  poisoning,  de- 
pending upon  a  foul,  infected  atmosphere,  operating 
upon  a  depraved  and  enfeebled  constitution.  It  most 
frequently  attacks  those  who  have  become  debilitated 
by  exposure,  disease,  want  of  proper  food,  intemper- 
ance, etc.;  so  that  in  a  crowded  hospital,  when  gan- 
grene threatens  to  devastate  the  wards,  you  might 
select,  in  advance,  the  cases  which  will  most  probably 
be  first  attacked.  At  times,  however,  it  engrafts 
itself  upon  all  wounds,  whether  trivial  or  serious; 
whether  in  enfeebled  or  robust  patients,  and  whether 
recent  or  newly  cicatrized,  the  presence  of  a  wound 
ensuring  an  attack.  Many  surgeons  consider  it  a 
constitutional  disease,  occurring  from  a  strictly  local 
cause  which  is  found  within  the  walls  of  the  hospital. 
All  surgeons  recognize  its  contagious  as  well  as  infec- 
tious character,  and  the  facility  of  transmitting  it  by 
sponges  or  dressings  used  in  common  by  inmates  of  a 
ward. 

The  facility  with  which  the  air  of  a  ward,  or  even  of 
a  hospital,  becomes  impregnated  with  this  poison, 
would  show  that  animal  exhalations,  especially  from 
those  suffering  under  this  disease,  possess  the  power  of 
diffusing  it.  Burgman  reports  that  hospital  gangrene 
prevailed  in  one  of  tho  low  wards  at  Leyden,  while 
the  ward  or  garret  above  it  was  free.  The  sin 
made  an  opening  in  the  ceiling  between  the  two,  in 
order  to  ventilate  the  lower  or  affected  ward,  and  in 
thirty  hours  three    patients  hi  the   upper  room,  who 


236  CONTAGION    OF    HOSPITAL    OANORENE. 

lay  next  the  opening,  were  attacked  by  the  disease. 
which  soon  spread  through  the  whole  ward. 

Guthrie  confirms  the  above  by  his  experience,  which, 
he  says,  left  no  doubt  upon  the  mind  of  any  one  who 
had  frequent  opportunities  of  seeing  the  disease,  that 
one  case  of  hospital  gangrene  was  capable  of  infecting 
not  only  every  ulcer  in  the  ward,  but  in  every  ward 
near  it,  and,  ultimately,  throughout  the  hospital,  how- 
ever extensive  it  may  be. 

Both  English  and  French  surgeons  in  the  Crimean 
war  recognized  the  atmosphere  as  clearly  the  vehicle 
of  its  extension,  and  that  its  increase  or  diminution 
depended  upon  the  more  or  less  crowded  condition  of 
the  wards,  and  the  amount  of  ventilation.  They  also 
observed  the  certainty  with  which  it  increased  when 
the  same  sponges  were  used  indifferently  for  gangre- 
nous and  for  healthy  wounds.  It  may  be  considered  a 
thoroughly  contagious  disease. 

Those  who  observe  the  march  of  the  healing  process 
of  wounds,  without  and  within  hospitals,  know  how 
easily  the  one  is  cured,  and  with  what  difficulty  a 
tedious  cure  is  obtained  in  the  other.  "Where  the  ex- 
halations from  many  suppurating  wounds  are  concen- 
trated in  a  ward,  the  cicatrization  of  all  wounds,  even 
the  most  simple,  is  retarded,  and  contagion  of  any 
kind  readily  propagated. 

There  are  certain  conditions  of  the  atmosphere  in 
cities  under  which  hospital  gangrene  or  sloughing 
phagedcena  shows  itself,  where  its  appearance  can  not 
be  attributed  to  over-crowding,  want  of  caro  or  clean- 
liness, nor  to  any  appreciable  cause.  During  the 
year  1863  we  passed  through  such  an  atmospheric 
condition,  when  the  phagedenic  sloughing  of  wounds 
was  epidemic,  and  so  general  was  this  complication 
that  even  the  small  prick   in  vaccination  would,  in 


SYMPTOMS    OF    HOSPITAL    GANGRENE.  237 

some  instances,  become  frightful  ulcers,  and  even  lead 
to  the  destruction  of  life. 

In  military  hospitals,  the  hospital  gangrene  will  be 
recognized  by  the  following  appearances  :  Although  the 
patient  may  have  recently  shown  feverish  symptoms, 
with  loss  of  appetite,  yellowish  or  pale  skin,  dirty 
tongue,  and  deranged  bowels,  the  first  appearance  of 
the  disease  is  recognized  in  the  changes  which  the 
wound  undergoes,  which  has  led  many  to  believe  it 
to  be,  at  first,  a"  local  disease,  in  time  infecting  the 
system.  The  granulating  surface  of  a  healthy  sore, 
about  taking  on  this  sloughing  condition,  becomes 
comparatively  dry  and  painful.  The  laudible  pus, 
which  lip  to  this  time  was  formed  upon  the  surface, 
disappears,  and  a  thin,  dirty,  watery  serum  bathes  the 
ulcer.  The  florid  hue  of  the  granulations  rapidly  dis- 
appears, and  is  replaced  by  a  dirty  gray  or  ash-colored 
slough,  which  fills  the  wound,  and  forms  a  pultaceous 
and  adherent  covering  to  the  granulating  surface.  As 
this  gray  slough  increases  in  extent  and  depth,  accom- 
panied by  a  severe  burning  pain  and  a  sensation  of 
weight  in  the  part,  the  surrounding  surface  becomes 
(edematous,  swollen,  and  of  a  livid  red  or  purplish 
color.  This  engorged  appearance  of  the  contiguous 
skin  always  precedes  the  advance  of  the  gray  slough. 
The  edges  of  the  ulcer  are  abruptly  cut,  undermined, 
ragged,  and  partially  everted,  assuming  an  irregularly 
circular  outline,  irrespective  of  the  form  of  the  wound 
prior  to  ijs  invasion.  The  gray,  tenacious  mass,  being 
formed  of  the  mortified  tissue,  and  containing  pieces 
of  dead,  blackened  matter,  holds  its  place  and  can  not 
l>c  wiped  off,  although  it  sways  to  and  fro  when  any 
attempt  is  made  to  cleanse  the  wound. 

The  liquefaction  of  these  mortified  tissues  soon  com- 
mences, and  a  dirty,  thick,  highly  offensive,  irritating 


238  8YMPTOM8   or   HOSPITAL   QANGBINX. 

fluid,  produced  from  the  putrefaction  of  tho  Blough, 
escapes  from  the  wound,  diffusing  a  peculiar  odor, 
which,  when  once  smelt,  will  always  be  recognised. 
This  is  the  poison  which  |"  such  powers  of  in- 

fection  when  brought  in  contact  with  healthy  wounds) 
and  which,  when  inserted  under  the  skin,  as  in  vacci- 
nation, will  soon  produce  a  similar  ulcer  t<>  that  from 
which  the  fluid  was  taken. 

Oner  the  disease  has  fairly  rooted  itself,  its  ravages 
are  extrusive  and  rapid.  One  can  nearly  Bee  the  ex- 
tending line  of  slough,  as  if  the  poisonous  fluid, 
bathing  the  wound,  possessed  corrosive  proper!  ies ;  and 
often  in  twenty-four  hours  large  portions  of  the  skin, 
Cellular  tissue,  and  muscles  will  have  mortified,  exca- 
vating immense,  frightful, ragged  cavities,  from  which 
strings  of  dead  membrane  bang,  and  in  the  bottom  of 
which  will  soon  he  found  destroyed  ligaments  ami  ten- 
dons, with  exposed  osseous  surfaces.  The  areolarand 
cutaneous  structures  are  the  mosl  readily  destroyed j 
the  muscular  and  fibrous  tissues  yielding  more  slowly, 
the  nerves  offering  the  greatest  resistance  to  destruc- 
tion. These  changes  in  the  wound  ;iml  surrounding 
-  are  accompanied  by  a  severe  burning,  sting- 
ing,  lancinating  pain. 

Pari  passu  with  this  local  destruction,  the  system  is 
gradually  or  rapidly  showing  the  influence  <>t  the 
poison.  Although  the  symptoms  may  he  at  first  of  an 
inflammatory  character,  accompanied  by  a  high  fever, 
the  pulse  soon  loses  its  strength  but  increases  in 
frequency,  the  mind  becomes  peevish,  fretful,  ami  de- 
sponding,  the  tongue  becomes  dry  and  brown,  the  skin 

pale,  and  the  countenance  anxious.  The  pain  accom- 
panying these  changes  is  often  so  Beverc  as  to  deprive 
tie-  patient  of  Bleep  and  -rcatly  depress  his  spirits. 
The  fobrile  accompaniments  of  the  disease  rapidly  as- 


SYMrTOMS    OF    HOSPITAL   GANGRENE.  239 

sumc  a  typhoid  cast,  with  eve*y  indication  of  phj^sical 
and  nervous  prostration.  Should  the  system  becomo 
overwhelmed  by  the  virulence  of  the  poison,  delirium 
ensues,  and,  with  a  tendency  to  coma,  becomes  a  prom- 
inent symptom. 

Should  the  caso  not  terminate  fatally  before  the 
elimination  of  the  sloughs  commences,  the  separation 
of  these  may  open  large  vessels,  from  which  hem- 
orrhage will  rapidly  destroy  life.  The  great  nerves 
and  arteries  appear  to  resist  the  gangrenous  destruc- 
tion longer  than  the  muscular  or  cutaneous  structures. 
These,  however,  yield  in  the  end,  and  repeated  hem- 
orrhages close  the  scene. 

When,  from  judicious  treatment  or  strength  of  con- 
stitution, the  disease  assumes  a  favorable  turn,  the 
sloughs  are  gradually  thrown  off,  healthy  pus  making 
its  appearance  over  the  face  of -the  wounds.  When- 
ever laudible  pus  is  seen  in  a  wound  which  had  been 
the  seat  of  hospital  gangrene,  it  may  be  considered  as 
the  sign  that  the  disease  has  been  checked,  and  a  very 
strong  indication  of  healthy  action  being  resumed  in 
the  part.  Granulations  readily  spring  up  over  the 
entire  surface  of  such  cavities,  pieces  of  dead  tendon 
slowly  coming  away.  When  not  sobbed  in  pus  they 
become  hard  and  black  from  exposure  to  air.  The 
blackened  surfaces  of  exposed  bones  also  arc  slowly 
thrown  off,  by  exfoliation,  from  the  surface,  and,  in 
time,  the  most  extensive  excavations  may  till  up  and 
cicatrize.  With  the  local  return  to  health  is  an  im- 
j  rovement  in  the  general  symptoms,  diminution  and 
final  disappearance  of  fever,  improvement  in  strength 
of  pulse,  return  of  appetite,  and,  with  it.  color  to  the 
cheeks,  and,  more  gradually,  restoration  of  strength, 
p  the  live  bloody  battles  around  Richmond  in 
the  summer  of  1862  (the  last  days  of  June  and  first  of 


240  EPIDEMIC   HOSPITAL  GANGRENE. 

Jul}-),  our  wounded  suffered  fearfully  from  hospital 
gangrene  in  the  hospitals  of  Richmond.  Previous  pri- 
vations and  hardships  had  broken  down  the  physique 
of  the  army.  Our  soldiers  had  not  yet  hecome 
veterans  inured  to  want,  hut  were,  on  the  contrary, 
much  enfeebled  by  camp  diseases  and  very  short 
rations.  Wounds  from  the  Richmond  battle-fields  took 
on  a  sloughing  condition  at  an  early  period,  and  amidst 
the  destruction  of  tissue  which  followed  more  or  less 
rapidly,  arteries  were  frequently  opened,  and  fatal 
cases  of  secondary  hemorrhage  were  numerous. 

I  witnessed  an  epidemic  of  hospital  gangrene  in 
Milan,  during  the  summer  of  1859.  A  large  number  of 
Austrian  wounded  had  been  put  in  a  barrack  prepared 
for  their  reception.  They  had  undergone  many  hard- 
ships, retreating  daily  before  a  victorious  enemy,  and 
had,  prior  to  the  Battle  of  Solferino,  tasted  no  food  for 
forty-eight  hours.  They  had  been  deceived  by  their 
leaders,  who  had  taught  them  that  certain  death 
awaited  them  should  they  fall  into  tho  hands  of  the 
Italians.  With  these  impressions,  the  wounded  hid 
themselves  in  the  ditches  and  underbrush  of  the  ox- 
tended  battle-field,  where  many  perished.  Some,  were 
not  discovered  for  two  or  three  days  after  the  battle, 
when  they  were  sent  to  the  hospitals.  The  previous 
hardships  which  the  Austrian*  had  undergone,  their 
lymphatic  tendencies,  their  irregular  living,  with  tho 
moral  depression  of  repeated  defeat,  exposed  them  to 
the  ravages  of  the  lowest  forms  of  disease.  Hospital 
gangrene  raged  fearfully  among  them,  destroying 
numbers.  Many  of  their  wounds  were  frightful  from 
tho  extended  sloughing,  and  their  worn  frames  and 
gaunt  visages  indicated  a  fearful  combat  with  disease. 
1  was  particularly  struck  with  the  mental  depression 
under  which  many  of  them  were  suffering — amounting 


EPIDEMIC    HOSPITAL   GANGRENE.  241 

to  despondency.  This  was  farther  increased  by  the 
attendants  and  surgeons  not  speaking  the  German 
language,  so  that  neither  could  their  wants  be  known 
nor  could  sympathy  be  extended  to  them.  From  the 
combination  of  these  depressing  causes,  an  epidemic  of 
sloughing  phagedoena  appeared,  which  was  appalling 
even  to  those  accustomed  to  see  disease  in  its  most 
fearful  form.  In  some,  the  muscles  forming  the  calves 
of  the  legs  had  sloughed  out,  leaving  frightful  cavities; 
while  in  others,  such  was  the  destruction  among  the 
muscles  of  the  thigh,  that  one  could  look  through  the  t 
limb. 

McLeod  tells  us  that,  in  the  Crimea,  during  the 
heat  of  the  summer  of  1855,  not  a  few  of  those  oper- 
ated upon  were  lost  by  a  gangrene  of  the  most  rapid 
and  fatal  form.  All  of  those  attacked  by  it  were  car- 
ried off.  In  the  case  of  a  few,  who  lived  long  enough 
for  the  full  development  of  the  disease,  gangrene  in 
its  most  marked  features  became  established;  but 
most  of  them  expired  previous  to  any  sphacelus  of  the 
part,  overwhelmed  by  the  violent  poison  which  seemed 
to  pervade  and  destroy  the  whole  economy.  "  The 
cases  of  all  those  who  died  in  my  wards  seemed  to  be 
doing  perfectly  well  up  to  sixteen  hours,  at  the  fur- 
thest, before  death.  Duringthe  night  previous  todeath 
the  patient  was  restless,  but  did  not  complain  of  any 
particular  uneasiness.  At  the  morning  visit  the  ex- 
pression seemed  unaccountably  anxious,  and  the  pulse 
very  slightly  raised,  tin'  skin  moist,  and  the  tongue 
clean.  Hy  this  time  the  stump  felt,  as  the  patient  ex- 
pressed it,  heavy,  like  lead,  and  a  burning,  stinging 
pain  had  begun  to  shoot  through  it.  On  removing 
the  dressing,  the  stump  was  found  slightly  swollen 
and  hard,  and  the  discharges  thin  and  gleety,  colored 
with  blood,  and  having  masses  of  matter,  like  gruel, 
u 


242  TREATMENT   OF   H08PITAL   QARQRRRS. 

occasionally  mixed  will)  it.     A  few  hours  afterward 

the  limb  would  Ik-  greatly  swollen,  the  skin  tense  and 
white,  and  marked  along  its  surface  by  prominent 
veins.  The  cut  edges  of  tbe  Btump  looked  like  pork. 
Acute  pain  was  tilt.  The  constitution  by  this  time 
had  began  to  sympathize.  A  cold  sweat  covered  tho 
body,  the  Btomaoh  was  irritable,  and  the  pulse  weak 
ami  frequent.  The  respiration  became  short  and  hur- 
ried, giving  evidence  of  the  great  oppression  of  which 
the  patient  so  much  complained.  The  heart'*  action 
gradually  and  surely  got  weaker,  till,  from  fourteen 
to  sixteen  hours  from  the  first  bad  symptom,  death 
relieved  his  Bufferings." 

In  the  treatment  of  hospital  gangrene^  we  must  con- 
sider it  frequently  a  local  disease,  with  rapid  tenden- 
cy, to  constitutional  poisoning.  One  of  our  early 
duties  would  he  to  destroy  the  accumulating  poisonous 
ichor  in  the  wound  to  prevent  further  infection,  while, 
at  the  same  time,  we  correct  those  depressing  causes 
which  predisposed  to  the  disease.  Guthrie  says  that 
constitutional  treatment,  and  every  kind  of  simple, 
mild,  detergent  applications,  always  failed  unless  ac- 
companied by  absolute  separation,  the  utmost  possi- 
ble extent  of  ventilation,  and  the  greatest  possible 
attention  to  cleanliness ;  and  not  oven  then,  without 
great  loss  of  tissue  in  man)'  instances. 

Tho  local  remedies  which  are  found  most  useful  act 
as  caustics,  and  comprise  tho  most  energetic  of  the 
pharmacopoeia.  Tho  French  and  German  military 
surgeons  prefer  the  actual  cautery  to  all  other  appli- 
cations to  check  tho  encroachments  of  the  disease, 
although  Arm  and  even  speaks  of  this  remedjr,  upon 
which  much  reliance  was  placed,  as  exceptionally 
checking  the  progress  of  mortification.  "After  a  thor- 
ough cauterization   the  eschar  separates  rapidly,  and 


TREATMENT    OP    HOSPITAL   GANGRENE.  243 

often  exposes  a  second  infected  surface  of  greater  ex- 
tent." His  individual  experience  gives  the  preference 
to  tincture  of  iodine  as  a  local  application.  The  best 
results  were  obtained  by  him  when  a  compress  satu- 
rated with  this  tincture  was  applied  to  the  wound. 

Guthrie  recommends  the  liberal  use  of  the  concen- 
trated mineral  acids,  especially  the  fuming  nitricacid. 
McLeod  refers  to  the  nitric  acid  as  the  most  efficacious 
means  of  stopping  the  sloughing  process. 

In  our  extensive  expci'ienee  we  do  not  hesitate  to 
give  preference  to  strong  nitric  acid,  which,  when  thor- 
oughly applied  to  every  part  of  the  wound,  will 
cheek  tho  advance  of  the  sloughing  process.  As  the 
application,  when  properly  done,  is  an  exceedingly 
painful  operation,  the  patient  should  have  previously 
had  a  large  dose  of  opium,  or  chloroform  should  be 
inhaled.  The  entire  surface  of  the  wound  should  then 
be  thoroughly  mopped  with  a  dossil  of  lint  saturated 
with  the  strong  acid,  which  should  be  allowed  to  run 
in  along  the  sinuosities  of  the  wound,  so  that  every 
portion  of  the  exposed  surface  might  be  converted  into 
an  eschar,  and  all  the  existing  fluids  of  the  wound  be 
destroyed  by  the  action  of  the  acid.  One  thorough 
application  will  suffice  to  control  any  case  of  hospital 
gangrene,  and.  if  accompanied  by  judicious  treatment, 
will  not  require  repetition.  Half-way  measures,  it 
must  be  remembered,  will  be  trifling  with  the  life  of 
the  patient.  The  surgeon  must  not  be  deterred,  by  the 
tear  of  giving  pain,  from  making  a  thorough  applica- 
tion of  the  caustic.  The  after-treatment  of  the  wound 
consists  iu  the  use  of  charcoal,  flaxseed,  or  meal  poul- 
tices, rendered  stimulating  by  an  admixture  of  pyro- 
ligneoue  acid,  turpentine,  or  creosote,  or,  what  is  flu? 
preferable,  lint,  raw  cotton,  or  old  soft  cloth,  saturated 
with  solutions  of  eitlier  of  these  fluids,  as  it  makes  a 


211      TREATMENT  OF  HOSPITAL  GANGRENE. 

much  cleaner, equally  useful,  and  more  convenient  ap- 
plication, When  the  sloughing  tissues  have  separated 
and  granulations  have  froely  sprung  up,  warm  water 
dressings  can  1"-  subs!  ituted. 

To  show  the  confidence  placed  upon  the  judicious 
application  of  strong  nitric  acid,  I  will  quote  a  few 
lines  from  one  of  many  reports  forwarded  to  the  Sur- 
geon-General's office  by  the  chief  surgeons  of  hospi- 
tals. Burgeon  <  'hamblis,  of  ( 'amp  Winder  hospital  an 
institution  of  three  thousand  beds),  speaks  as  follows: 
"  Nitric  acid  has  been  applied  in  every  case  of  hospi- 
tal gangrene  which  has  occurred  in  this  hospital  dur- 
ing the  past  year — in  every  case  with  benefit,  and  in 
most  cases  with  prompt  and  decided  success,  which 
may  always  be  exj ted  as  the  result,  if  properly  ap- 
plied." 

In  some  hospitals  the  persulphate  of  iron,  which  is 
a  powerful  acid  astringenl  and  cauterizing  fluid,  ap- 
plied with  similar  care,  was  found  equally  efficacious, 
and  is  spoken  of  as  establishing  a  slough  which,  when 
thrown  off,  leaves  a  clean,  nicely  granulating  surface; 
It  thoroughly  destroys  all  the  putrescent  tissues, 
making  a  dark,  pultaceous,  inodorous  slough,  which 
can  be  removed  by  syringing,  and  which  will  separate 
in  thirty-six  to  forty-eight  hours,  leaving  a  healthy 
surface.     This  application  does  not  destroy  or  excite 

Surrounding  tissues,  as  is  the  case  with  the  more  vio- 
lent nitric  acid  or  actual  cautery.  Strong  pyrol igne- 
ous acid,  when  poured  into  the  cavity  of  the  wound, 
was  found,  in  many  oases,  to  be  followed  by  equally 
satisfactory  results,  alt  hough  in  a  number  of  instances 
it  did  not  check  the  progress  of  the  disease. 

Labarraquc's  chloride  ol  soda,  creosote,  perchloride 
of  iron,  lemon  juice,  oil  of  turpentine,  a  combination  of 
quickdime  and  coal  tar,  etc.,  have  been  also  used  with 


TREATMENT   OF    HOSPITAL    GANGRENE.  245 

benefit;  but  general  experience  in  military  surgery 
gives  decided  preference  to  the  mineral  acid  prepara- 
tions. These  may  be  followed  by  irrigation  or  fre- 
quent syringing,  which  wash  away  the  ichorous  dis- 
charges as  rapidly  as  they  form,  and  prevents  further 
infection ;  also,  some  soothing  application  should  be 
made,  containing  stramonium,  conium,  morphine,  or 
some  anodyne  preparation,  in  solution,  to.  allay  the 
agonizing  pain  in  and  around  the  wound. 

The  local  treatment  alone,  without  the  constitu- 
tional, would  be  followed  by  no  good  results.  As 
hospital  gangrene  appears  pre-eminently  to  reside  in 
over  crowding,  the  most  important  of  all  the  constitutional 
remedies  is  change  of  air.  If  the  patient  could  be  re- 
moved from  the  atmospheric  influences  of  the  infected 
ward,  his  chances  for  recovery  would  be  greatly  in- 
creased. Baudens  states  that  without  isolation  all 
treatment  will  show  itself  powerless,  and  our  experi- 
ence has  confirmed  the  importance  of  ventilation.  An 
established  custom  in  the  organization  of  a  Confed- 
erate military  hospital  is  to  have  attached  to  the 
same  a  number  of  tents,  to  be  used  especially  for 
the  treatment  of  erysipelas  and  hospital  gangrene. 
Whenever  hospital  gangrene  shows  itself  in  a  wound, 
the  patient  is  immediately  removed  from  the  ward  to 
an  airy  tent,  where  the  thorough  application  of  nitric 
acid  is  made  to  tho  wound,  and,  under  the  gonoral  sup- 
porting plan  of  treatment,  improvement  appears  to 
show  itself  immediately.  Under  this  generally  adopt- 
ed coarse  of  treatment  hospital  gangrene,  the  fright- 
ful Bconrge  of  European  military  hospitals,  has  been 
robbed  of  all  its  terrors.  Fresh  air  is  the  great  remedy, 
Every  day.  when  the  weather  permits,  the  sides  of  the 
tent  are  tucked  Dp,  BO  as  to  allow  the  free  circulation 
of  air.     Cleanliness  must  he  insisted  upon.     Quinine, 


246  I'V.v.mia. 

or  the  muriated  tincture  of  iron,  is  administered  as  :i 
tonic — brandy  or  whiskey  freely  used — strong,  nutri- 
tious food  given  ad  libitum,  and  we  expect  the  patient 
to  recover.  Barely  are  we  disappointed  in  establish- 
ing a  cure. 

Keeping  the  intestinal  action  free  by  a  little  blue 
mass,  or  compound  extract  of*  colocynth,  will  be  re- 
quire" i. 

Opium  is  required  in  every  stage  of  this  dis< 
and  is  administered  in  large  and  repeated  doses  to 
allay  the  pain,  irritability,  ami  sleeplessness  which  so 
generally  attend  the  severe  cases  of  gangrene.  The 
diet  throughout  should  be  highly  nutritious,  ami  should 
be  liberally  prescribed.  Although  wounds,  under  the 
influence  of  hospital  gangrene,  assume  frightful  ap- 
pearances, the  inexperienced  surgeon  can  not  be  too 
urgently  warned  against  amputating  limbs,  unless 
driven  to  it  to  save  life,  from  the  disastrous  effects  of 
frequently  recurring  hemorrhages.  The  stump  will 
at  once  take  a  similar  condition  of  sloughing,  and 
soon  a  more  extensive  ulcer  than  the  one  for  which  he 
amputated  will  show  him  that  he  has  risked  the  pa- 
tient's life,  by  a  serious  operation,  without  having  im- 
proved his  condition. 

Pyjemia,  a  disease  very  common  in  Europe,  and  a 
scourge  of  their  military  hospitals,  was  but  seldom 
met  with  in  the  Confederate  States  until  it  became 
necessary  to  mass  large  numbers  of  wounded  in  crowd- 
ed and  badly  ventilated  wards,  as  after  the  many 
bloody  battles  of  the  past  three  years.  When  it  shows 
itself  in  European  hospitals,  like  its  kindred  disease, 
erysipelas,  it  is  not  satisfied  until  it  has  swept  off  its 
hundreds.  After  the  battles  of  the  Crimea  those  re- 
quiring amputation  were  severely  alllicted  by  pyajmia. 


PYEMIA.  247 


nearly  one-fourth  of  those  operated  upon  being  carried 
off  by  this  frightful  scourge.  In  civil  hospitals  it  is  not 
the  less  frequently  met  with,  us  we  are  informed  by 
European  writers  that  it  destroys  forty-three  per  cent, 
of  all  fatal  primary  amputations  and  twenty-five  per 
cent,  of  all  fatal  secondary  amputations — ten  per  cent, 
of  all  amputations  dying  from  pyaemia.  In  some  of  our 
militarj^  hospitals  it  has  proved  fatal  to  several  of  our 
wounded ;  at  no  period,  however,  has  it  appeared  as  an 
epidemic,  with  its  hundreds  of  victims.  During  the 
years  1862  and  1863,  before  buildings  were  especially 
erected  for  military  hospitals,  and  when  houses,  how- 
ever badl}*  suited,  were,  from  necessity,  used  as  wards 
for  our  wounded  men,  we  find  but  fifty-two  cases  of 
pyaemia  reported  by  army  surgeons.  At  the  same 
time  fifteen  hundred  and  seven  amputations  of  large 
limbs  were  reported  as  having  been  performed  from 
October,  18G2,  to  October,  1863 — only  a  portion  of  the 
interval  referred  to  above.  Although  this  number  is 
not  supposed  to  represent  every  case  that  occurred 
during  that  period,  it  is,  nevertheless,  sufficiently  near 
the  truth  to  show  that,  comparatively,  it  is  a  rare 
disease  in  the  Confederate  army.  Of  these  fifty-two 
cases  but  one  cure  is  reported,  which  also  indicates 
that  it  has  lost  none  of  its  malignancy  when  con- 
trasted with  its  European  fac-simile. 

The  great  similarity  in  causes,  symptoms,  and 
effects,  are  sufficient  grounds  for  associating  this  with 
the  huge  class  of  aesthenic  diseases,  among  which  ery- 
sipelas and  hospital  gangrene  are  prominent.  It  is 
impossible  to  control  the  symptoms  and  prevent  a  fatal 
issue,  when,  as  acute  pyaemia,  it  seizes  upon  the 
wounded  in  military  hospitals;  it  is,  therefore,  much 
more  to  !"■  feared  than  its  kindred  diseases  just  men- 
tioned.    Although  this  disease   is   always   associated 


248  SYMPTOMS    OF    PYiEMIA. 

with  injuries,  no  wound,  however  trivial  or  however 
well  advanced  toward  cicatrization,  is  safe  from  its 
attack  until  completely  healed.  The  disease  is  sup- 
posed to  be  caused  by  a  vitiated  condition  of  the 
atmosphere  from  over-crowding  in  badly  ventilated 
wards,  and  by  the  absorption  of  the  ichorous  fluids 
decomposing  in  the  wound,  which  produces  a  general 
poisoning  of  the  blood,  rendering  it  unfit  for  sustain- 
ing life.  It  has  been  called  an  acute  decomposition 
of  the  blood. 

The  most  conspicuous  phenomena  which  accompany 
this  affection  are,  great  depression  of  the  powers  of 
the  system,  and  the  formation  of  abscesses  in  various 
parts  of  the  body.  In  the  incubative  stage,  which 
may  precede  the  explosion  of  the  disease  by  twenty- 
four  or  thirty-six  hours,  the  patient  is  restless,  anxious, 
ill  at  ease,  with  forebodings  of  impending  trouble.  He 
looks  pale  and  sallow,  has  loss  of  appetite,  and  gener- 
ally deranged  secretions.  The  disease  commences  by 
severe  chills  of  long  duration,  which,  in  the  acute 
cases,  are  repeated  with  much  irregularit}'.  In  the 
subacute  variety  these  chills  appear  at  such  regular 
intervals,  followed  by  high  fever  and  terminating  in 
profuse  sweats,  as  to  induce  the  belief  of  the  existence 
of  malarial-fever.  In  many  cases  the  skin  is  hot,  with 
a  pungent  feel,  irrespective  of  the  chills;  in  others 
the  chilly  and  feverish  sensations  alternate,  the  skin 
being  at  times  clammy  and  often  jaundiced.  The 
pulse  is  quick  and  feeble;  face  pale,  with  anxiety  of 
countenance;  tongue  foul,  with  a  tendency  to  become 
dry,  and  for  sordos  to  collect  upon  the  teeth  ;  the 
stomach  is  uneasy,  with  bilious  vomiting,  and  constant 
thirst.  The  suspension  of  secretions  gives  a  dull,  yel- 
lowish, icteric  tint  to  the  skin. 

As  the  pulse  becomes  more  and  more  enfeebled,  the 


THEORY    OF    PUS    FORMATION.  249 

patient  may  complain  of  pains  in  his  joints,  simulating 
rheumatism,  and,  simultaneous  with  these,  a  reddening 
of  the  skin,  with  swelling  of  the  joints.  Collections  of 
a  purulent  character  will  soon  after  be  detected,  dis- 
tending the  synovial  sacs.  Collections  also  occur  in 
the  cellular  tissue,  and  even  in  the  substance  of  organs. 
These  form  rapidly  and  without  much  inconvenience. 
Often  the  swelling  alone — which  has  appeared  during 
the  night,  unaccompanied  with  pain,  redness,  or  heat — 
indicates  that  a  large  collection  of  pus  has  already 
taken  place. 

While  these  symptoms  progress,  the  wound  usually 
becomes  foul  and  sloughy,  ceasing  to  secrete  pus. 
This  is  not  the  invariable  rule,  as  surgeons  have  noticed 
cases  in  which  the  appearance  of  the  wound  was  no 
indication  of  the  destructive  disease  which  had  laid  its 
relentless  hand  upon  the  injured.  The  disease  may 
even  run  its  fatal  course  without  material  changes  in 
the  wound.  Certain  injuries  are  more  likely  to  be 
followed  by  pyaemia;  and  those  of  bones  and  joints  are 
said  to  be  peculiarly  exposed  to  it.  As  in  the  kindred 
diseases  of  low  type,  typhoid  symptoms  ensue  at  an 
early  day,  and  usually  carry  off  the  patient  at  the  end 
of  the  first  week.  Often'  stupor  comes  on  as  early  as 
the  fourth  day,  having  been  preceded  by  delirium. 
An  examination  after  death  will  reveal  a  rapidly  ad- 
vancing decomposition,  with  gas  in  the  blood-vessels 
and  purulent  collections  in  many  organs,  as  the  lungs, 
liver,  spleen,  kidneys,  heart,  and  brain.  Similar  col- 
lections are  found  in  most  of  the  large  joints,  besides 
the  multiplied  abscesses  of  the  cellular  tissue. 

The  theory  of  the  metastatic  character  of  the 
abscesses,  or  the  sudden  change  of  place  of  such  de- 
posits, by  absorption  and  redeposit,  has  long  been 
abandoned.     Pus  we  now  believe  to   be   a    modified 


250  THEORY  OF  PUS  FORMATION. 

nutrient  fluid,  which,  from  an  impairment  of  its  vital- 
izing principle,  falls  short  of  its  object  of  repairing 
tissues.  During  the  healthy  action  of  living  tissues 
they  arc  constantly  bathed  in  a  plastic  fluid  which 
they  draw  from  the  blood-vessels  for  their  support. 
Under  ordinary  acute  inflammation  this  exudation  of 
plasma  is  freely  drawn  by  excited  tissues,  which  are 
not  able  to  consume  the  excess  of  nutriment  which 
they  have  taken  from  the  circulation.  This  plastic 
fluid,  now  at  rest  without  the  blood-vessels,  and  not 
being  used  for  the  nourishment  of  the  affected  tissues, 
attempts  a  formation  of  its  own,  developing  cells  in 
this  plasma  which  simulate  closely  the  white  cells  in 
the  progressive  development  of  the  blood,  and  which 
are  supposed  by  some  pathologists  to  be  identical 
with  them.  The  effused  fluid  exhausts  its  developing 
vitalizing  power  in  this  creation,  and  all  further 
changes  in  it  are  of  a  retrograde  nature.  This  cellu- 
lar fluid  is  pus.  When,  from  some  special  cause,  the 
entire  circulating  fluid  has  become  poisoned,  its  en- 
tire plasma  or  liquor  sanguinis  is  impaired.  It  is  from 
this  plasma,  under  ordinary  conditions,  that  the  blood- 
cells  are  to  be  generated.  The  usual  process  of  devel- 
opment is  commenced,  white  cells  form  as  colorless 
blood  corpuscles,  and  when  the  continued  develop- 
ment into  the  red  or  perfect  cell  is  attempted,  many 
failures  occur.  There  are,  besides,  many  which  had 
exhausted  their  formative  powers  in  attaining  the  de- 
gree of  development  necessary  to  perfect  the  white 
cell,  and  remaining  as  such,  continuo  in  the  circu- 
lation. When  the  blood  of  a  pyamiie  patient  is  ex- 
amined, a  very  large  number  of  such  colorless  cells 
are  found  in  the  blood,  even  in  sufficient  quantity  to 
modify  its  color,  and  it  is  in  autopsies  that  the  sepa- 
ration of  these  white  cells  from  the  generating  fluid 


HOW    TO    PREVENT    PYyEMIA.  251 

shows  the  appearance  of  pus  in  the  blood  or  emboli 
in  the  large  vessels  at  the  heart. 

Blood  in  this  condition,  with  an  impaired  liquor 
sanguinis,  is  unfit  for  its  duties  as  a  life-supporting 
fluid.  The  various  tissues  of  the  bod)',  not  receiving 
the  kind  of  nourishment  appropriate  for  their  healthy 
function,  become  irritated.  Nature  tries  to  make  up 
the  dcficienc}'  in  qualit}-  by  quantity.  The  irritated 
parts  are  supplied  with  an  excess  of  the  impaired  nu- 
tritive fluid,  which,  being  eliminated  from  the  capil- 
laries, is  received  into  the  tissues.  This  is  rapidly 
converted  into  pus,  by  the  development  of  white  or 
colorless  cells  in  it,  which  is  the  height  of  vitality  in 
such  an  exudate. 

Experience,  which  helps  to  sustain  this  view,  shows 
the  disease  to  be  purely  a  blood  poisoning — a  general 
disease,  with  its  local  manifestations.  When  the  blood 
has  been  thus  thoroughly  deteriorated,  no  remedy 
which  art  possesses  can  restore  it  to  its  former  health}' 
condition,  and  the  patient  necessarily  dies — there  be- 
ing no  case  of  acute  pyaemia  which  has  ever  been  re- 
ported cured. 

As  there  is  no  course  of  treatment  for  acute  pyaemia 
which  promises  any  good  results,  we  must  direct  our 
energies  where  they  can  really  be  useful.  Our  great 
remedy  lies  in  prevention.  The  hygienic  precautions 
of  rigid  cleanliness,  thorough  ventilation,  good  food, 
and  proper  shelter,  without  over-crowding,  will,  if  prop- 
erly insisted  upon,  go  far  to  keep  away,  if  they  do  noo 
altogether  prevent,  the  occurrence  of  pyaemia.  When 
this  disease  threatens,  too  much  attention  can  not  bo 
paid  t<>  I  he  detail  of  cleanliness  in  the  wards.  Theslop- 
DUCketS,  which  are  such  a  niusance,  should  be  imme- 
diately emptied,  scoured  daily  with  lime,  and  always 
kepi    covered,  that  the  emanations  arising   from   de- 


252  HOW   TO    PREVENT   PYEMIA. 

composing  urine,  which  is  very  deleterious  in  hospi- 
tal wards,  can  not  escape.  The  bed  and  body  linen 
of  the  patients  should  be  daily  changed;  doors  and 
windows  must  be  kept  open.  If  any  difficult}7  exists 
in  this  respect,  from  the  inattention  of  nurses  or  fears 
of  patients,  it  would  be  better  to  takeout  the  sashes, 
so  as  to  ensure  continued  renewal  of  the  atmosphere 
da}'  and  night. 

There  is  a  general  dread  of  night  air  among  our 
people,  which  should  be  exploded.  The  purest  air  we 
have  in  cities  is  the  night  air,  and  is  the  very  article 
which  is  so  much  needed  in  hospitals.  If  the  patient  is 
properly  covered  in  bed,  there  is  no  fear  of  his  taking 
cold  or  contracting  other  injury  from  the  continued  re- 
newal of  pure  air.  Men  who  live  in  the  open  air,  and 
are  protected  by  no  other  roof  than  the  arched  sky 
above  them,  never  have  catarrhal  affections.  These 
precautions  must  not  be  commenced  when  pyaemia 
has  already  shown  itself,  but  are  those  necessary  to 
be  taken  wherever  the  seriously  wounded  are  treated) 
or  some  low  form  of  fatal  disease  will  soon  break  out. 
Any  one  who  will  visit,  during  the  night,  a  ward 
filled  with  suppurating  wounds,  will  perceive  the  de- 
gree of  vitiated  air  which  the  patients  are  inhaling, 
and  see  the  necessity  for  free  ventilation. 

It  is  a  bad  principle  to  concentrate  the  seriously 
wounded;  always  scatter  them  over  a  building, 
mixing  them  in  with  , inmates  from  other  diseases. 
This  increases  the  available  space  for  tho  seriously 
wounded,  and  prevents  a  depressing  effect,  by  diffus- 
ing the  emanations  from  so  many  extensive  suppurat- 
ing wounds.  It  is  for  a  similar  reason  that  we  have 
already  recommended  that  rooms  should  not  be  kept 
too  long  in  use  when  occupied  by  tho  severely  wound- 
ed.    As  the  air  becomes  poisoned,  the  ward  requires 


HOW    TO    PREVENT    PYAEMIA.  25o 

to  be  unoccupied,  for  purification,  two  weeks  of  every 
two  months,  during  which  interval  it  is  thoroughly 
cleansed  and  whitewashed. 

When  pyaemia  threatens  to  become  general  in  a 
military  hospital,  the  seriously  wounded  should  be  put  in 
tents,  or  allowed  double  space  in  a  constantly  ventilated 
room.  Sixteen  hundred  cubic  feet  would  not  be  too 
much  for  every  occupied  bed.  An  additional  quantity 
of  nourishing  food  should  also  be  given  out  to  all  the 
wounded ;  besides  which,  whiskey  or  malt  liquors 
should  be  daily  issued.  Feeding  the  wounded  on  light 
broths  and  other  slops  is  paving  the  Avay  to  the  de- 
bility which  is  a  precursor  of  pyaemia.  At  such  times, 
when  pyaemia  makes  its  appearance,  all  small  opera- 
tions should  be  avoided,  and  even  the  hasty  opening  of 
abscesses  guarded  against.  The  best  protection  against 
this  disease  is  a  whole  skin. 

When  the  acute  form  of  the  disease  shows  itself, 
surgery  can  do  but  little  to  assist  the  patient.  More 
benefit  will  be  derived  from  changing  the  patient  into 
fresh  air  than  from  any  other  remedy  ;  and,  if  he  can 
be  saved,  it^vill  only  be  by  putting  him  in  a  tent  in 
which  he  can  be  constantly  surrounded  by  an  ever- 
changing  atmosphere.  Our  entire  reliance  should 
be  placed  upon  the  stimulating  tonics.  Strong,  nutri- 
tious, easily-digested  food,  the  free  use  of  stimuli,  with 
opium  to  allay  pain  and  restlessness,  are  the  remedies 
indicated.  The  tendency  to  delirium  should  not  [in- 
vent the  free  use  of  this  last  remedy,  for  although  it 
would  increase  the  difficulty  if  it  be  given  in  inflamma- 
tion of  the  brain  or  meninges,  it  allaj-s  pain,  removes 
restlessness,  stops  muttering,  and  induces  quiet  Bleep, 
when  given  in  cases  of  debility  accompanied  by  de- 
lirium. As  in  erysipelas,  the  acid  preparations  of 
iron,  as  a  blood  tonic,  may  be  administered  with  ad- 
vantage. 


254  HOW    TO    PHKVENT    PTiBMIA. 

Although  so  little  is  to  be  expected  in  the  actte  form 
of  blood  poisoning;  in  the  Bnbacute  or  chronic  pyemia 
much  benefit  will  be  derived  firom  rigidly  pursuing  the 
course  of  treatment  just  marked  out.  By  the  Bti mu- 
tating and  supporting  plan,  with  change  of  air,  many 
patients,  after  a  long  struggle,  ma}-  be  saved. 

The  important  indication  for  local  treatment  in 
pyemia  is  to  prevent,  by  cleanliness,  the  accumulation 
of  putrescent  fluids  in  the  wound,  and  l>y  the  frequent 
application  of  chlorinated  washes,  which  also  remove 
foetor  and  stimulate  the  granulating  surface.  The 
abscesses  which  form  during  the  march  of  the  disease 
should  not  be  too  hastily  opened,  as  this  course,  pur- 
sued with  the  numerous  collections,  will  induce  rapid 
prostration. 

It  is  thus  seen  that  the  three  most  fatal  complica- 
tions to  gunshot  wounds  are  the  three  kindred  dis- 
eases— erysipelas,  hospital  gangrene,  and  pyemia — all 
recognizing  a  common  origin,  viz:  imperfect  ventila- 
tion, and  want  of  proper  attention  to  cleanliness,  with 
the  abscenco  of  those  h3Tgienic  regulations  necessary 
for  the  healt  h  of  an  army.  • 

With  proper  care  from  the  medical  corps,  these  dis- 
eases, which    are  the  chief    BCOUrgCS   to    the  wounded, 

and  the  causesofa  large  percentage  of  deaths,  can  bo 
in  a  measure,  if  not  altogether,  prevented. 

Once  they  have  made  their  appearance  iii  a  hospital, 
they  will  never  he  got  rid  of  until  the  building  is 
dosed,  and  the  proper  measures  for  purification  re- 
sorted to.  Prevention,  in  this  instance,  as  in  all  oth- 
ers, will  he  found  better  than  attempts  at  cure,  as 
many  of  these  diseases,  once  they  appear,  are  found 
quite  unmanageable,  and  tend  naturally  to  a  fatal  is- 
sue. All  of  these  diseases  are  benefited  by  the  isola- 
tion <>f  the  patient  in  a  pure  atmosphere,  when  the 
infectious   character  of  the  disease  is  counteracted,. 


HECTIC    FEVER.  255 

and  the  patient  is  in  the  host  condition  for  successful 
treatment.  In  all  of  them  the  antiphlogistic  treatment 
can  not.  be  too  severely  condemned,  'flic  support  inn;  plan, 
with  stimulating  tonics  and  liberal  diet,  is  the  only 
rational  course  that  promises  success,  and  should  be 
followed  throughout  the  treatment.  Attending  to  the 
secretions  with  mild  remedies,  allaying  pain,  and  in- 
ducing refreshing  sleep  by  means  of  opium,  good, 
strong,  easily-digested  food,  and  due  regard  to  hygi- 
enic regulations,  will  be  the  course  of  practice  to  bo 
pursued. 

Hectic  Fever. — The  not  unfrequent  sequela  of  se- 
vere gunshot  wounds  is  long-continued  discharge,  pro- 
ducing emaciation  and  hectic,  with  its  gradual  disso- 
lution of  body  and  soul.  It  is  not  at  all  surprising 
that  the  daily  discharge  from  a  wound,  when  at  all 
profuse,  should  cause  debility,  as  we  have  already 
characterized  pus  as  the  nutritive  essence  of  the  cir- 
culating fluid.  If  the  surgeon  who  has  suppurating 
wounds  under  his  care  overlooks  the  fact  that  he  must 
make  allowance  for  this  drain,  and  feed  the  wound  as 
well  as  the  patient — the  wound  being  more  imperious 
in  its  demands  than  the  economy,  deprives  the  latter 
of  its  duo  supply  of  nourishment,  and  progressive 
starvation,  which  we  call  emaciation,  must  follow. 
It  is  on  this  account  that  what  is  called  the  antiphlo- 
gistic treatment,  when  fully  carried  out  in  the  treat- 
ment of  suppurating  wounds,  is  so  injurious,  and  that 
the  supporting  plan  is  required. 

With  diet,  we  have  a  powerful  weapon  for  weal  or 
in  surgical  practice.  Soon  after  injuries  have 
been  received,  when  reaction  runs  high,  by  abstemi- 
ousness we  can  do  much  to  quiet  excessive  irritabil- 
ity     Bui  as  soon  as  this  stage  has  passed,  and  sup- 


HECTIC    NEVER. 

paratloa   has  l>< me  established,  then  the  court 

<lict  Bhould  be  modified.  Now  liberal  diet  is  necessa- 
ry to  prevent  that  febrile  complication  which,  in  t he 
early  stage  of  the  wound,  abstemiousness  controlled. 

The  use  of  an  abundance  of  strong,  nutritions  food, 
with  stimuli,  by  enriching  the  blood,  will  increase  the 
vital  properties  of  the  plasma,  improve  1 1 1 » >  tone  of 
tli«'  tissues,  Btop  tlnv  excessive  demands  of  the  irritated 
Wounded  parts,  ami  diminish  tht'  drain.  This  t rest- 
raint, with  the  liberal  use  of  theastringent  tonics,  espe- 
cially the  preparations  of  iron,  the  use  of  cod  liver  oil, 
and  the  injection  of  stimulating  astringents  into  the 
wound  |  a-  nitrate  of  silver,  ten  grains  to  one  ounce  of 
water,  <>r  tincture  of  iodine,  or  the  acid  tinctures  of 
iron  diluted,  or  pyroligneous  acid,  one  part  to  five  of 
water*),  will  gradually  diminish  a  discharge  which,  un- 
der less  supporting  treatment,  would  continue  for  a 
much  longer  period.  The  economy  can  not  withstand 
this  constanl  drain  of  pus.  A.s  its  nutrient  fluid  escapes 
from  the^ wound,  the  system  becomes  irritable  in  its 
weakness  In  its  efforts  to  throw  oft*  this  yoke,  it  still 
further  enfeebles  itself.  Daily  fevers,  with  their  pro- 
fuse  sweats,  reappear  with  fearful  regularity.  Finally 
the  blood  becomes  so  poor  that  it  deteriorates  even 
more  rapidly.  The  effete  matter  or  useless  material 
which  is  rapidly  accumulating  in  nio blood,  ami  which 
is  ejected  from  the  circulation,  irrritates  the  organ* 
through  which  it  passes,  causing  diarrhesa,  and  also 
copious  deposits  in  the  urine.  This  quadruple  drain 
from  wound,  skin,  bowels,  and  kidueys,  can  not  long 
be  resisted.  Debility  daily  increases,  the  patient  rapid. 
lv  wastes  to  a  living  skeleton,  having  literally  melted 
away,  and  at  last  dies  from  sheer  exhaustion — the 
conjoined  result  of  malnutrition  and  wasting  dis- 
charges.    Such  is  hectic  fever. 


TETANUS.  257 

Tetanus. — Another  fatal  complication  of  wounds, 
depending,  however,  upon  very  different  circum- 
stances from  those  recently  considered,  is  tetanus,  or 
lockjaw — a  disease  fearfully  malignant  under  any  cir- 
cumstances, and,  with  very  few  exceptions,  in  military 
surgery.  Fortunately,  this  is  never  an  epidemic,  nor 
can  it  infect  a  hospital,  although  pathologists  have  re- 
cently attempted  to  prove  its  origin  traceable  to  an 
animal  poison.  This  disease,  although  comparatively 
common  among  our  negro  population,  has  but  rarely. 
been  met  with  in  military  practice,  and  is  not  more 
frequent  among  our  wounded  than  it  is  in  Europe, 
where  it  is  rarely  met  with.  In  the  Crimean  service 
McLcod  m-entions  but  thirteen  cases  as  occurring  in 
camp  and  in  the  hospitals. 

This  disease,  which  does  not  depend  upon  the  size 
of  the  wound  from  which  the  patient  is  suffering,  ap- 
pears to  be  caused  frequently  by  sudden  atmospheric 
changes  in  connection  with  dampness.  Larrey,  in  his 
experience  both  in  Germany  and  EgjTpt,  found  it  in 
those  wounded  who,  after  sustaining  great  exertions 
during  the  fight  on  a  very  hot  day,  were  exposed  to  the 
cold.  dain]i  night  air  on  the  field  without  shelter.  After 
the  Battleof  Bautzen,  where  the  wounded  wcrelefton 
the  field  during  the  night,  exposed  to  severe  cold,  Lar- 
rey found  on  the  following  morning  that  more  than 
one  hundred  were  affected  by  tetanus.  No  such  effects 
have  followed  the  leaving  of  wounded  soldiers  upon 
the  battle-fields  of  the  Confederacy.  In  the  thickets 
which  cover  the  face  of  the  country,  and  in  which  bat- 
tle- often  rage,  some  of  those  who  fall  escape  the  ob- 
servation of  those  insearch  of  them,  and  remain  two 
and  three  day  8  exposed  to  the  elements.  Such  wound- 
ed we  have  not  found  more  liable  to  tetanus  than 
those  immediately  eared  for.  In  very  hot  climates  it 
v 


2.38  SYMPTOMS    OF    TETANl  - 

requires  but  little  excitement  to  produce  it — a  trifling 

puncture  or  scratch  is,  at  times,  sufficient  to  cause  an 
attack;  and  it  has  been  noticed  by  military  Burgeons 
that  the  scraping  of  the  skin  by  a  ball,  with  bruising  of 
tho  nerves,  is  more  liable  to  tliis  complication  than 
the  more  Bevere  wounds. 

Tho  proximate  cause  appears  to  be  some  injury  to 
the  nerves,  not  necessarily  connected  with  an  open 
wound,  as  it  has  been  known  to  follow  the  Mow  of  a 
whip  or  a  Bprain.  Wounds  in  certain  situations  are 
thought  to  favor  its  appearance,  viz:  injury  to  the 
hands,  feet,  joints,  etc.  It  may  occur  very  speedily — 
a  few  hours  after  the  injury  has  been  received — or  it 
may  not  occur  for  days.  Rarely  does  it  complicate 
chronic  wounds  after  the  twentieth  day.  Its  common 
period  for  appearing  is  between  the  fifth  and  fifteenth 
day,  when,  pei-hap-.  thesimple  wound  has  completely 
cicatrized. 

The  premonition  of  anoasincsa  on  tho  part  of  the 
patient,  with  vague  fears  of  impending  trouble,  dis- 
turbed digestion,  etc.,  are  not  often  observed.  Usu- 
ally the  first  symptom  which  we  recognize  is  a  com- 
plaint of  soreness  of  the  throat,  which  in  ordinary 
cases  precedes,  liy  some  hours,  the  contraction  of  the 
muscles  of  the  jaw  and  pinching  of  the  features.      This 

symptom  is  often  mistaken  for  a  common  son'  throat 

connected  with  some  catarrhal  affection,  and  is  treated 

accordingly — the  true  character  of  the  symptom  be- 
ing usually  overlooked.  The  spasm,  instead  of  com- 
mencing in  the  injured  part,  usually  shows  itself  first 

in  those  muscles  supplied  by  the  fifth  pair  of  nerves; 
and  although,  in  sudden  and  violent  cases,  the  spas- 
modic contraction  of  the  muscles  generally  may  rapid- 
ly follow  the  locking  of  tho  jaws,  or  appear  to  be 
even  simultaneous  with  it,  they  are  rarely  found  to 


SYMPTOMS    OF    TETANUS.  25(J 

precedo  it.  The  locking  of  the  jaws;  the  contrac- 
tion of  the  muscles  of  the  neck,  especially  the  sterno- 
cleido-mastoids,  which,  b}~  bounding  under  the  skin, 
accurately  defines  the  triangles  of  the  neck;  the  pain- 
ful sensation  of  tightness  about  the  ensiform  carti- 
lage, as  if  the  chest  were  in  an  iron  coil  ever  contract- 
ing; the  hardened  condition  of  the  abdominal  mus- 
cles, with  knots  forming  over  the  region  of  the  recti 
muscles  during  the  paroxysm  of  spasm ;  the  stiffen- 
ing of  the  muscles  of  the  legs,  while  those  of  the 
arms  remain  free  ;  the  sardonic  expression  of  the  face, 
with  drawn  mouth  and  pinched  features;  clear  in- 
tellect; sleeplessness;  extreme  restlessness;  profuse 
sweating;  incessant  desire  to  drink,  and  extreme  diffi- 
culty in  accomplishing  it;  the  occurrence  of  parox- 
ysms of  violent  muscular  contractions  every  few  min- 
utes, with  loss  of  strength  in  the  pulse,  and  rapid  pros- 
tration— define  so  accurately  the  disease  that  it  is  one 
in ost  easily  recognized. 

An}T  one  who  has  ever  felt  a  cramp  in  the  calf  of 
the  leg.  may  have  a  faint  appreciation  of  the  intense 
pain  which  a  permanent  and  violent  cramp  of  all  the 
muscles  of  the  body  must  produce — a  pain  sufficient  to 
destroy  life  promptly,  through  nervous  exhaustion. 

The  prognosis  of  this  disease  is  so  serious,  and  the 
treatment,  however  conducted,  so  unsatisfactory,  that 
man}-  surgeons  of  large  experience  have  never  had  a 
of  traumatic  tetanus  to  recover  under  their  treat- 
ment. That  fruitful  source  of  information,  pathology, 
gives  ns  no  instruction  in  this  disease.  An  autopsy 
La  to  the  eye  nothing  commensurate  with  tho 
intensity  of  the  symptoms.  A  slight  congestion  of  the 
spinal  COrd  and  medulla  oblongata  is  all  that  can  he 
ned.  Prom  the  symptoms,  we  judge  of  the  dis- 
as  one  of  intense  nervous  irritation.      \l<  cognising 


260  TREATMENT  OF  TETANUS. 

the  exhaustion  which  so  soon  and  with  such  certainty 
shows  itself,  the  treatment,  as  laid  down  by  the  most 
recent  authors,  and  the  one  now  generally  adopted,  is 
one  of  support  to  both  the  nervous  and  muscular 
systems. 

Larrey  lias  cut  short  the  disease,  in  its  incipient 
stage,  by  amputating  the  limb,  or  dividing  the  nerve; 
which  is  supposed  to  he  at  fault.  Other  surgeons,  by 
isolating  the  irritation,  have  been  equally  successful. 
Such  results  are,  however,  rarities  in  practice,  the 
operations  nearly  always  failing  even  when  performed 
simultaneously  with  the  very  first  symptoms,  and 
always  when  the  disease  becomes  confirmed  with  gen- 
eral  spasms.  At  times,  patients  suffering  from  tetanus 
get  well  under  the  mosl  varied  treatment.  Nearly 
every  powerful  remedy  in  the  pharmacopoeia  has  been 
recommended  as  a  sovereign  cure  by  those  who  may 
have  derived  Borne  benefit  from  sueh  in  the  treatment 
of  tetanus.  Disappointment  is  sure  to  follow  the  con- 
fidence placed  in  any  oi  these  articles.  The  most 
judicious  course  is  to  disclaim  all  specific  remedies,  ami 
be  guided  by  the  symptoms.  Allay,  if  possible,  the 
intense  nervous  excitement,  and  the  local  cause  of  irri- 
tation by  which  tic  disease  is  occasioned,  and  support 
the  system  against  the  ensuing  exhaustion,  both  hy 
sustaining  the  patient's  Btrength  with  strong,  easily- 
digested  food,  and  by  procuring  sleep,  so  as  to  allow  the 
nervous  system  an  opportunity  of  regaining  its  wasted 
powers. 

The  local  treatment  should  consist  in  examining  the 
wound  for  fore ign  bodies,  and  removing  them,  if  pos- 
sible, as  they  are  frequently  the  exciting  cause  of 
nervous  irritation,  under  the  presumption  that  unless 
the  local  cause  be  removed  we  can  expect  hut  little 
abatement  of  the  general  tetanic  excitement.     .Should 


TREATMENT    OF   TETANUS.  261 

no  foreign  body  be  found,  if  it  be  possible,  an  incision 
should  be  made  on  the  cardiac  side  of  the  wound,  so  as 
to  divide  the  nerves  implicated,  and  paralyze  their  sen- 
sibility. The  powerful  acids  and  the  actual  cautery 
have  been  recommended  for  the  similar  purpose  of  de- 
stroying the  excited  nerves  at  the  seat  of  injury. 
Although  the}*  may  be  at  times  useful,  I  have  seen  fatal 
tetanus  produced  from  ulcers  under  the  cauterizing 
treatment;  and  I  have  recently  lost  a  case,  after  ampu- 
tation of  the  leg,  from  gunshot  fracture  of  the  tibia,  in 
which  mortification  had  attacked  the  entire  stump. 
In  this  instance,  after  arresting  the  sloughing  by  the 
liberal  use  of  fuming  nitric  acid,  and  succeeding  in  es- 
tablishing a  well  defined  line  of  demarcation,  tetanic 
symptoms  appeared  and  destined  tire  patient  in  thir- 
ty-six hours.  A  solution  of  morphine,  atropine,  aco- 
nite, or  kindred  preparations,  may  be  instilled  into  the 
wound,  for  their  sedative  action,  and  the  water  dress- 
ing, medicated  with  these  remedies,  continued. 

If  it  be  a  E-mail  member  wounded,  such  as  a  finger  or 
toe,  an  early  amputation  may  stop  the  spasm  by 
removing  the  irritating  cause,  and,  therefore,  'should 
be  tried  in  all  eases.  This  amputation  should  be  per- 
formed irrespective  of  the  local  appearances  of  the 
.wound,  and  even  if  it  be  nearly  cicatrized.  .Should 
tlic  injured  extremity  be  in  a  sloughy  state,  so  as  to 
render  its  recovery  doubtful,  amputation  should  be 
performed  at  any  stago  of  the  disease.  When  tetanus 
supervenes  upon  an  amputation,  the  surgeon  would  bo 
justified  in  performing  a  second  amputation  upon  tho 
early  establishment  of  the  symptoms,  as  good  results 
mighl  follow  siieh  ;i  course. 

The  constitutional  treatment  will  have  for  its  object 
tho  removal  of  all  those  general  and  local  causes  winch 
may  keep  up  excitement.      !i'<  should  constantly  bear  in 


262  TREATMENT  OF  TETANUS. 

mind  that  tetanus  is  an  affection  of  debility ,  and  tbat  the 
violence  of  the  spasmodic  paroxysm  gives  &  false  ap- 
pearance of  strength  to  the  patient,  while  the  principal 
source  of  danger  and  <l*:it  li  is  from  exhaustion,  induoed 
by  the  excessive  energy  of  the  muscular  movements, 
and  the  consequent  want  of  rest. 

Tn  hospital  practice,  remove  the  patient  at  once 
to  a  small  room  or  tent,  where  he  will  be  alone  with 
his  single  attendant.  Ah  the  bowels  are  always  con- 
stipated and  loaded  with  offensive  foecal  collections, 
which  might  assist  in  sustaining  the  excitement  of 
the  nervous  system,  the}''  should  be  at  once  emptied 
by  large  doses  of  calomel,  with  gamboge,  aloes,  or 
podophyllum.  When  a  difficulty  is  found  in  adminis- 
tering these,  from  the  locked  condition  of  the  jaw, 
two  or  three  drops  of  croton  oil  can  be  placed  within 
the  teeth,  which,  mingling  with  the  saliva,  will  bo 
swallowed.  Three  or  four  times  the  ordinary  dose 
will  be  required  to  relieve  the  torpid  bowels.  The 
patient  should  then  be  kept  perfectly  quiet — if  possi- 
ble, by  himself,  as  the  stirring  about  of  persons,  noises, 
draughts,  etc.,  excite  sudden  and  repeated  paroxysms 
of  spasm.  Ice  bladders,  blisters,  or  chloroform  appli- 
cations, may  be  made  to  the  upper  portion  * » 1"  the 
spine  to  allay,  if  possible,  the  irritation  of  this  nervous 
centre. 

Although  opium  is  universally  administered  as  an  in- 
ternal  sedative,  its  good  effects  are  not  often  obtained 
even  when  given  in  largo  doses.  It  is  believed  thai  it 
remains  unabsorbed  in  the  Btomach,  and  therefore  ex- 
hibits no  action.  The  same  of  conium,  hyoscyamus, 
and  the  entire  class  of  sedatives,  when  given  in  the 
form  of  pill  or  extract.  Unless  medicines  are  given 
dissolved,  they  are  not  likely  to  be  absorbed,  or  they 
are  taken  up  so  slowly  that  their  good  effects  are  not 
perceived. 


TREATMENT  OP  TETANUS.  263 

.Recently,  in  two  cases  of  traumatic  tetanus,  I  havo 
tried  the  endermic  administration  of  morphine  in  one- 
third  grain  doses,  dissolved  in  a  few  drops  of  water, 
and  injected  by  means  of  a  Wood's  syringe.  In  a  few 
minutes  the  effect  of  the  remedy  was  decided,  but  it 
was  not  persistent.  By  its  use  partial  relaxation  of  the 
{jaws  could  always  be  effected,  so  that  the  taking  of 
nourishment  was  much  facilitated;  sleep  could  also  be 
induced.  It  is  by  far  the  preferable  mode  of  using 
opium,  as  its  effects  can  be  speedily  and  with  certain- 
ty obtained.  In  one  case,  in  which  I  injected  one- 
tenth  of  a  grain  of  atropine  under  the  skin  of  the  arm, 
the  effect  upon  the  pulse  was  so  immediate  that,  in  five 
minutes,  it  had  increased  from  eighty  to  one  hundred 
and  fifty  beats.  It  rapidly  affected  the  salivary  and 
mucous  glands  of  the  mouth — diminishing  their  secre- 
tions, without,  however,  producing  dilatation  of  the 
pupils  or  causing  relaxation  of  the  muscles.  As  no 
beneficial  effect  followed  the  atropine  injection,  mor- 
phine had  to  be  used,  when  relaxation  to  a  certain 
extont  was  immediately  obtained. 

The  liberal  use  of  belladonna  has  been  recommend- 
ed, and,  from  its  great  utility  in  relieving  congestions 
of  the  lower  portion  of  the  spinal  cord,  we  might  natu- 
rally infer  similar  good  effects  upon  the  medulla  ob- 
longata. The  tincture  of  cannabis  indica  has  been 
highly  extolled.  Some  cases  have  recovered  under  its 
use,  but  a  very  much  larger  number  have  died  in  spite 
of  its  administration.  The  tinctures  of  vcratrum  vir- 
idis  and  golseminum  sempervirens  are  also  favorite 
remedies  with  some,  who  speak  <>f  them  as  valuable 
means  for  calming  the  excited  action  of  the  heart  and 
relaxing  the  stiffened  muscles.  Stimulating  and  nour- 
ishing fluids  must  be  liberally  administered  at  regu- 
lar  intervals,  and,    notwithstanding   the   difficulty   in 


264  TREATMENT   01   TKTAH 

swallowing,  the  nurse  should  insist  upon  their  being  tak- 
en. Many  a  fatal  case  can  DC  laid  to  tin-  charge  of  care- 
lessness in  the  attendance,  where  the  wishes  of  the 
patient  are  permitted  to  regulate  the  nurse's  duties. 
Beef  lea,---;-,  milk,  custards,  eggnog,  and  similar  ar- 
ticles of  concentrated  fluid  nourishment,  with  wine, 
brandy,  or  whiskey,  must  be  frequently  poured  down  th& 
throat  of  the  unwilling  patient;  ami  if  the  mouth  can 
not  be  sufficiently  opened,  the  inhalation  of  chloro- 
form, or  the  endermic  use  of  morphine,  should  be  free- 
ly used  to  effect  it.  I  have  seen  excellent  results  from 
either  of  these  relaxing  agents.  I  have  found  porter 
an  excellent  tonic  in  such  cases,  as  it  combines  both 
sedative,  nourishing,  and  stimulating  or  supporting 
properties.  The  amourf!  of  stimulus  to  be  adminis- 
tered must  not  be  measured  by  the  health  standard. 
as  I  do  not  believe  that  intoxication  can  be  induced 
while  the  system  is  laboring  under  tetanus.  1  believe 
that  if  inebriation  could  be  brought  about  it  would 
mark,  in  many  cases,  the  commencement  of  convales- 
cence. Under  the  frequent  inhalation  of  chloroform 
the  spasms  can  often  he  kept  under  control. 

By  pursuing  the  above  course  of  keeping  the  pa- 
tient <|iiiet,  using  nervous  sedatives,  with  forced  nour- 
ishment, giving  si  iniulus  freely. and  relieving  the  loaded 
intestines  by  croton  oil,  I  have  had  the  good  fortune 
of  saving  three  tetanic  patiertfS  oul  of  six  cases  which 
have  come  under  ray  personal  observation.  As  the 
three  first  cases  which  I  treated  were  all  restored  to 
health,  although  tiny  were  very  Severe  ca-es  (,f  trau- 
matic tetanus,  1  imagined  that  I  had  found  a  success- 
ful mode  of  treating  this  dreadful  disease,  and  publish- 
ed the  same  in  the  Charleston  Medical  Journal  for 
lsf>7.  Since  that  time  1  have  had  throe  cases  under 
Observation  and  lost  them  all,  notwithstanding  the 
name  course  was  pursued  as  in  the  successful  cases. 


TREATMENT  OF  TETANUS.  265 

When  tho  patient  is  able,  constant  smoking  of 
strong  cigars  may  be  useful  in  quieting  the  excited 
nervous  system.  The  impression  among  many  ob- 
serving surgeons  is,  that  the  patient  is  destroyed  by 
exhaustion — called  by  some  staiwation.  It  is  known 
that  if  the  patient  can  be  kept  alive  to  the  sixth  day 
after  the  attack,  there  is  a  likelihood  of  his  recovery, 
and  that  by  the  tenth  day  he  may  even  bo  considered 
convalescent.  If  the  debilitating  effects  of  the  dis- 
ease can  be  counteracted  by  the  free  administration 
of  very  nutritious  food,  such  as  brandy,  eggs,  etc., 
many  surgeons  believe  that  the  nervous  irritation 
will  wear  itself  out.  It  is  based  upon  this  belief,  and 
the  known  failures  attending  the  spoliative  plan  of 
treatment,  that  the  above  plan  is  urged. 

Woorara  poison  has  been  recommended  as  an  anti- 
dote, from  its  known  powerful  sedative  nervous  ac- 
tion, and  its  marked  influence  in  counteracting  the 
effects  of  strychnia.     When  poisonous  doses  of  these 
substances  are  given  conjointly,  no  poisonous  effects 
arc  observed.     The  striking  similarity  betAveen  the 
spasms  produced   by  strychnine  and  those  of  lock- 
jaw suggested  the  use  of  woorara  in  this  latter  disoase. 
As  experiments  proved  it  efficacious  in  the  tetanus  of 
animals,  its  field  of  usefulness  was  enlarged  to  the  hu- 
man subject,  and  several  cases  of  its  successful  adminis- 
tration  in  chronic  tetanus  are  reported.     It  was  first 
used  by  inoculation ;  now  it  is  given  in  the  form  of  a 
mixture:  ten   grains  of   the  woorara  to  a  six-ounce 
mixture— a  tablespoonful  every  half  hour  until  perfect 
relaxation  is  produced.     Should  poisonous  effects,  with 
death-like  symptoms,  show  themselves  from  an  over- 
dose, artificial  respiration  will  support  life  and  sus- 
tain the  action  pf  the  heart  until  the  poison  is  elimi- 
nated  from    the   circulation    by   the    kidnoys.       Tho 
w 


PERIODIC    PA1NI 

rationale  ol  the  remedy  is  to  keep  the  spasms  from 
killing  the  patient  by  their  violence,  until  the  morbid 
state  calling  thorn  into  play  has  exhausted  itself. 

Prom  the  known  influence  of  quinine  in  diminishing 
the  pulse,  and  its  tendency  to  mitigate  Bpasms,  many 
consider  it  a  useful  drug  in  tetanus,  and  speak  of  h 
remedy  well  worthy  of  trial.     Cures  have  been  effect- 
ed under  its  liberal  m 

An  expression  which  we  frequently  hear  from  a 
lain  class  of  surgeons  is:  "That  the  wounded  under 
their  charge  were  threatened  with  tetanus,  but  the  dis- 
ease was  kept  off  by  judicious  and  timely  treatment." 
The  community  take  uj>  the  refrain  in  resounding  the 
praise's  of  their  skilful  attendants.  Although  we  have 
had  large  experience  in  the  treatment  of  wound-,  we 
are  still  at  a  loss  to  understand  the  above  expression. 
We  do  not  believe  that  tetanus  ever  idly  threatens,  or 
that  there  is  any  symptoms  by  which  wecan  l>e  led  to 
suspect  the  probable  occurrence  of  the  disease.  When 
our  Buspioions  are  aroused  tetanus  has  already,  by 
unmistakable  Bigns,  laid  its  iron  hand  upon  its  victim. 
and  can  not,  by  any  treatment  which  we  may  insti- 
tute, be  suddenly  checked  in  its  well  known  pro 
sive  march.  We  do  not  know  of  any  abortive  treat- 
ment for  tetanus. 

Periodic  Pains. — Another  Bcquela  of  gunshot 
wounds  is  more  or  less permanent  or  periodicpain  in  the 
injured  limb,  connected  or  not  with  paralysis  of  certain 
muscles — the  nervous  supply  to  which  has  been  im- 
paired or  destroyed  by  the  ball  in  its  passage.  When 
a  nerve  has  been  completely  divided,  permanent  pa- 
ralysis of  the  part  supplied  by  it,  and  atrophy  of  the 
muscles,  ensue — the  limb  gradually  dwindling,  if  the 
muscles,   indirectly  destroyed,   he   important   to   the 


PERIODIC    PAINS.  267 

common  movements  of  the  extremity.  A  bruising  of 
the  nerves,  without  division,  is  also  followed  by  a 
paralysis  more  or  less  persistent,  which  time,  however, 
and  stimulating  embrocations,  will,  to  a  certain  extent, 
remedy. 

In  sabre  wounds,  in  which  the  nerve  is  neatly  divided 
and  the  tissues  not  displaced,  the  wound  heals  usually 
throughout  its  entire  extent  without  suppuration,  and 
sensibility  and  voluntary  motion  may  slowly  return. 
Both  experiments  upon  animals  and  experience  in  man 
show  that  a  reunion  of  the  ends  of  the  nerves  may  be 
effected  when  divided  by  a  sharp  cutting  instrument. 
and  nervous  action  restored  to  its  former  integrity. 

When  nerves  are  pricked,  or  in  any  other  way 
injured  without  complete  division,  very  severe  neural- 
gic pains,  with  spasmodic  action  of  the  muscles  of  the 
limb,  may  be  occasioned.  These  pains,  which  are 
often  paroxysmal  in  their  character,  extend  up  and 
down  the  injured  limb,  and,  as  in  cases  reported  by 
Guthrie,  have,  with  irregular  intermissions,  annoyed 
tin-  patient  for  years.  In  one  case,  although  the 
severity  of  the  symptoms  subsided  after  six  or  seven 
years,  annoyance  was,  at  times,  experienced  forty 
years  after  the  injury  had  been  received.  A  coldness 
of  the  parts  supplied  by  the  injured  nerve  is  not  an 
uncommon  effect,  and  is  more  or  less  persistent.  Sud- 
den changes  in  temperature,  cold  weather,  or  mental 
excitement,  an  among  the  exciting  causes  of  such 
attacks. 

The  pains  referred  to  are  not  such  as  are  occa- 
sioned by  the  presence  of  foreign  bodies — as  a  hall 
making  injurious  pressure  upon  a  nerve  at  some  por- 
tion of  if-  -but  are  apparently  caused  by  an 
Irritation  of  the  oerve  trunk,  extending  a  sympathetic 
irritation  through   all   branches  distributed  from   the 


TRACK    OF    A    QUN8HOT    W01  ni> 

From  this  cause, induced  by  a  gunshot  injury 
in  the  groin,  I  have  seen  irregular  periodic  paii 
great  intensity,  radiating  from  the  groin  and  extend- 
ing throughout  the  entire  limb,  In  one  case,  although 
the  wound  had  healed  up  readily,  still.  :it  the  end  of 
two  years,  the  periodic  pains,  in  Bevere  paroxysms; 
jted,  notwithstanding  the  most  varied  treatment. 
An  after-pain,  which  nearly  all  those  wounded  in  the 
inferior  extremity  experience,  and  which  is  mo 
less  persistent,  accompanies  ;i  simple  flesh  wound. 

When  a  ball  traverses  a  limb,  it-  penetration  is 
effected  by  a  combined  movement  which  separates, 
divides,  and  destroys  the  tissues,  all  of  these  effects 
being  more  or  less  present  in  by  far  the  majority  of 
cases,  lip-''  effects  are  very  evident  in  the  skin, 
which,  in  certain  c;im  s,  appears  as  if  its  fibres  had  been 

divided;   at  Other  times,  its  fibres  hive  evidently  been 

torn,  while,  in  the  majority  of  cases,  there  is  an  actual 
destruction  of  skin.     The  perforated    cellular   tissue 

pr<  B(  nts  a  canal  with  contused  walls,  that   firm  in  tin' 

centre  of  the  canal  corresponding  with  the  axis  of  the 
ball,  being  destroyed  and  booh  mortifying.  The  fibrous 
li-sws  may  meet  with  a  loss  of  substance,  hut  usually 
present  an  irregular  tearing,  amounting,  bo  me  times, 
to  a  split  or  separation  of  the  fibres,  to  give  passi 
the  projectile.  The  muscular  tissues  yield  readily  to 
the  hall,  which,  by  dividing  and  tearing,  forms  a  canal, 
the  diameter  of  which  will  depend  upon  the  degree  of 
tension  of  the  muscles,  [f  relaxed  when  traversed  bj 
the  hall,  the  subsequent  contraction  of  the  fibre  will 
give  the  appearance  of  much  greater  loss  of  substance 
than  it  the  muscle  were  in  tension,  when  its  relaxation 
would  elongate  the  fibre  and  tend  to  close  the  canal. 
As  all  the  muscles  of  the  limb  arc  never  in  the  same 
condition  of  tension  or  relaxation,  a  ball,  in  perforat- 


TRACK    OF    A    GUNSHOT    WOUND.  209 

in<;-,  would  find  them  in  various  stages  of  contraction, 
which  would  result  in  an  irregular  canal ;  at  points  so 
constricted  as  to  have  its  continuity  nearly  interrupted, 
at  other  points  widely  dilated.  In  the  healing  of  a 
wound,  the  first  effort  of  nature  is  so  to  arrange  the 
various  tissues  involved  in  the  track  of  a  ball  as  to 
bring  like  tissues  in  contact,  and  then  keep  them  at  rest 
until  perfect  union  can  be  obtained.  This  is  effected 
by  means  of  plastic  lymph,  which,  as  a  natural  glue,  is 
poured  out  freely  among  all  the  tissues. 

When  a  ball  perforates  the  limb  and  suppuration  is 
established,  the  wound,  in  healing,  forms  adhesions  to 
contiguous  tissues,  all  of  which,  through  the  entire 
thickness  of  the  limb  traversed  by  the  ball,  are  more 
or  less  matted  together,  the  nerves  being  more  or  less 
squeezed  by  this  excessive  effusion  of  solid  matter. 
The  object  of  this  free,  plastic,  interstitial  deposit  is  to 
prevent  retraction  or  displacement  in  the  injured  tis- 
sues, and  enable  nature  to  secrete  her  remodelling 
material  upon  a  firm  basis,  and,  by  degrees,  reunite 
the  separated  parts  of  similar  structures. 

After  cicatrization  there  is  a  large  amount  of  absorp- 
tion of  fibrinous  adhesions  necessary  before  the  limb 
can  regain  its  former  movements  and  the  muscles  of 
the  extremity  play  freely  within  their  cellular  envelope 
without  disturbing  contiguous  structures.  Until  this 
absorption  liberates  the  respective  tissues,  every  action 
of  a  muscle  involved  in  the  wound  must  draw  upon 
adherent  and  hypersensitive  nerves,  which,  in  turn, 
produces  pain.      It  is  OH  this  account  that  a  very  large 

number   of    wounded,   for   months    alter   their   flesh 

wounds  have  completely  cicatrized.  Miller  more  '>r  less 

ely  whenever  they  attempl  to  use  their  injured 
limbs,  and  are  only  at  ease  when  at  r< 
In  the  latter  class  of  cases,  which  are  those  con- 


270  TREATMENT   OP    PERIODIC    PAINS. 

stantly  met  with  in  hospital  practice,  the  indications 
for  treatment  are  sufficiently  obvious.  Promote  the 
rapid  absorption  of  the  effused  lymph  ami  liberate  the 

nerves  from  the  traction,  while  at  the  same  time  the 
irritation  or  increased  sensitiveness  of  the  nerve  is 
mitigated,  and  the  pain  complained  of  will  gradually 
disappear.  The  best  means  of  meeting  these  indica- 
tions are  in  the  free  use  of  stimulating  narcotic  em- 
brocations. Any  combination  from  the  many  arti< 
of  the  materia  medica,  of  stimulating  and  narcotic,  or 
anaesthetic  ingredients,  would,  in  most  cases,  give  the 
desired  relief.  An  excellent  and  very  efficient  liniment 
for  rubbing  such  a  painful  limb  could  be  made  by  dis- 
solving  two  ounces  of  any  of  the  essential  oils  of  the 
9uPply  table  and  one  ounce  of  chloroform  in  five  mm 
of  alcohol — frictions  with  this  liniment  to  be  made  on 
the  limb  twice  daily.  Camphorated  soap  liniment, 
containing  laudanum,  forms  also  a  highly  useful  appli- 
cation. Each  surgeon  will,  however,  be  guided  by  his 
own  experience  in  combining  ingredients  for  the  relief 
of  this  class  of  cases.  The  internal  use  of  quinine, 
aconite,  hyoscyamus,  belladonna,  or,  more  especially, 
opium,  will  blunt  sensibility,  and  will  be  required, 
during  the  course  of  treatment,  as  constitutional 
remedies. 

In  the  treatment  of  every  case,  if  possible,  the 
patient  should  obtain  sleep  at  night,  and,  with  this  ob- 
ject in  view,  opium,  in  some  form,  is  constantly 
administered  at  bedtime. 

The  endermic  use  of  morphine  in  one-fourth  grain 
doses,  or  aconitine,  one-sixteenth  of  a  grain,  dissolved  i  u 
two  or  three  drops  of  water,  has  given  immediate  relief 
when  all  other  anodynes,  administered  in  large  doses, 
have  failed  to  mitigate  the  pain.  I  place  great  con- 
fidence in  the  endermic  use  of  morphine,  as  I  have 


TREATMENT    OF    PERIODIC   PAINS.  271 

never  injected  it  without  obtaining  prompt  and  decided 
relief.  In  some  instances  a  permanent  cure  has  fol- 
lowed the  first  injection.  Great  reliance  will  hereafter 
be  placed  upon  this  new  method  of  treatment.  In 
some  cases  the  persistent  pain  is  found  to  depend  upon 
a  diseased  condition,  with  subsequent  enlargement  of 
the  nerve  at  the  seat  of  injury.  As,  in  such  cases,  the 
treatment  recommended  above  will  only  give  tempo- 
rary relief,  a  complete  division  of  the  nerve  at  fault  has 
been  recommended  and  practiced  with  some  good 
results.  But  as  we  have  already  referred  to  the  fact 
that  a  nerve,  divided  with  a  sharp  instrument,  so«n 
becomes  reunited,  and  the  pain,  in  many  cases,  return- 
ing when  union  is  perfected,  it  has  been  suggested,  as 
a  more  effective  operation,  to  cut  down  upon  the  neu- 
roma or  nerve  tumor,  and  remove  all  the  enlarged 
portion.  In  simple  flesh  wounds  this  proceeding  is 
very  rarely  called  for — time,  with  stimulating  anodjnie 
embrocations,  being  usually  sufficient  to  effect  a  per- 
manent cure. 


CHAPTER    VIII. 

TREATMENT   OF    WOUNDB   OF    THE    DIFFERENT    PARTS    OF    THE    BODY,   OR 

Topical  Surgery — Wounds  or  thb  Bead — Concussion;  its  CHAR- 
ACTERS AND  TREATMENT — COMPRESSION  J  ITS  SYMPTOMS — VARIETY 
OF      WolNDS     OF      THE     HeAD;      THEIR     PROGNOSTIC     VALUE  —  SlMPLE 

Wound  of  the  Scalp;  Treatment — Fracture  without  Depres- 
sion;   COURSE   TO   BE    PURSUED    WHEN   INFLAMMATION   OF    THE   BllAIX 

threatens — Fracture,  with  Depression,  to  be  treated  without 
an  Operation — Trephining  very  rarely  called  for — Compound 
Fracture,  with  Depression  and  Compression;  Trephining  even- 
here  OF  DOUBTFUL  PROPRIETY — PERFORATING  WOUNDS  OF  THE  CRA- 
NIUM complicated  with  Foreign  Bodies. 

Wounds  of  the  head,  when  received  in  battle,  require 
a  special  treatment,  which  can  not  be  engrossed  in  the 
routine  practice  for  wounds.  Owing  to  the  proximity 
of  the  brain  and  membranes,  and  the  facility  with 
which  shocks  or  direct  injury  can  be  transmitted 
through  the  protective  envelopes,  injuries  of  the  head 
possess  a  peculiar  significance.  All  wounds  of  the 
head  are  more  or  less  serious,  as  the  surgeon  can  never 
know  in  advance  whether  the  brain  be  injured,  and 
what  amount  of  irritation  or  inflammation  will  ensue 
upon  such  an  occurrence.  Hence  the  necessity  of 
caution  in  prognosis  and  treatment,  which  the  experi- 
enced surgeon  will  always  exhibit,  however  trivial  the 
wound  may  appear. 

Injuries  of  the  head  would  divide  themselves  into 
those  produced  from  shot,  small  fragments  of  shell,  or 
from  a  bayonet  thrust — those  from  large  portions  of 
shell,  or  from  clubbed  musket — and  those  caused  by 
the  blow  of  a  sabre.    Wounds  are  found  of  every  grade 


WOUNDS    OP   THE    HEAD.  -<•> 

of  intensity,  from  a  simple  scratch  to  extensive  de- 
struction of  the  soft  and  bard  parts,  with  or  without 
those  phenomena  recognized  as  concussion  and  com- 
pression. As  these  terms  will  be  continually  referred 
to  in  speaking  of  the  treatment  of  head  injuries,  we 
will,  in  brief,  define  the  meaning  which  the  surgeon 
attaches  to  them. 

Co?icussion,  or  stunning,  appears  to  be  a  shock  to 
the  brain,  by  which  its  substance  is  more  or  less 
shaken,  with  interference  of  its  circulation,  and  often 
injury  to  its  structure,  and  with  suspension  of  its 
functions  for  a  certain  period. 

Immediately  as  an  injury  upon  the  head  has  been 
received,  if  at  all  severe,  the  patient  is  knocked  sense- 
less. He  lies  perfectly  insensible,  motionless,  and  all 
but  pulseless.  His  face  and  surface  becomes  pale  and 
cool;  the  breathing,  although  feeble,  is  regular  and 
easily  perceived;  the  pupils  irregularly  contracted  or 
dilated;  sphincters  are  relaxed,  in  common  with  the 
entire  voluntary  muscular  system,  so  that  the  con- 
tents of  the  bladder  and  bowels  often  escape  involun- 
tarily. After  continuing  in  this  condition  for  a  few 
minutes,  hours,  or  days,  he  gradually  recovers  consci- 
ousness. The  heart  first  regains  its  accustomed  action, 
the  pulse  gradually  undergoes  development,  and  the 
skin  becomes  warmer.  At  this  period  vomiting  usu- 
allv  comes  on,  which  arouses  the  action  of  the  heart. 
This  organ,  under  the  excitement  of  emesis,  drives 
blood  to  the  brain,  and  with  this  free  supply  of  stimu- 
lus to  the  general  controlling  organ, the  patient  rapidly 
rallies. 

This  is  the  common  picture  of  concussion  as  seen 
in  surgical  practice,  and  the  combination  of  its  symp- 
toms will  be  more  familiarly  recognized  as  those  simi- 
lating  ordinary  fainting  or   syncope.     The   extremes 


-7 1  PATHOLOGY    OP   I  .\. 

would  be  those  cases  in  which  the  patient  stag 
Imt,  after  supporting  himself  for  an  instant  against 
some  house,  fence,  or  tree,  recovers  himself,  and  with- 
out further  annoyance  continues  his  employment;  or 
those  in  which  the  patient  is  picked  up  apparently 
dead,  with  relaxed  muscles,  pair  surface,  glassy  eyes, 
scarcely  perceptible  pulse,  and  very  feeble  and  irregu- 
lar respiration.     The  death-like  appearance  in  such 

Cases   Of  severe    concussion    becomos    more    and    more 

confirmed,  the  breathing  gradually  ceases,  and   the 

pulse  imperceptibly  flitters  away,  without  any  sign  of 
consciousness  from  the  moment  of  injury. 

In  fatal  cases,  where  concussion  had  been  present) 
the  brain  has  been  found  more  or  less  injured,  and  so 
highly  congested  as  to  exhibit  a  dusky  hue.  Fissures 
have  been  found  in  its  substance,  or  extravasations  of 
blood  in  numerous  or  concentrated  spots.  In  certain 
instances  the  brain  has  apparently  shrunk  from  the 
excessive  shaking  or  vibrations  to  which  it  has  been 
subjected,  so  that  it  no  longer  tills  the  cavity  of  the 
skull.  In  some  fatal  eases,  where  the  brain  had  been 
fissured,  the  commotion  among  its  particles  had  appa- 
rently at  once  annihilated  its  functions,  so  that  the 
heart's  action  had  instantly  ceased,  and  no  blood  had 
been  driven  to  the  mangled  brain  to  be  extravasated 
into  its  substance.  In  some  cases  of  nearly  inslauta- 
neous  death  from  concussion  or  stunning,  the  brain. 
Upon  examination, appeared  in  every  reaped  healthy, 
the  lesion,  in  its  Bubstance,  not  being  perceptible  to 
the  eye.  On  the  other  hand,  in  cases  of  perfect  re- 
covery alter  concussion,  where  the  patient  had  lived 
\n\-  a  considerable  period  (  weeks  or  months)  in  the  full 
enjoyment  of  all  his  faculties,  and  had  died  from  some 
disease  totally  foreign  to  the  former  head  injury,  ex- 
tensive lesions  have  been  found  in  the  brain,  and  traces 


TREATMENT    OF    CONCUSSION.  Z(0 

of  largo  and  extended  extravasations  of  blood,  which 
covered  the  hemispheres,  as  well  as  traces  of  blood 
clots  in  the  cerebral  substance.  The  irritable  condi- 
tion of  the  brain  in  which  the  patient  is  often  left, 
after  concussion  of  limited  duration,  with  the  impair- 
ment of  memory,  or  of  some  one  of  the  special  senses, 
or  even  partial  paralysis  of  the  limbs,  would  be  phys- 
iological proof  of  cerebral  injury.  Although  its 
symptoms  are  usually  transient,  we  may,  doubtless, 
Consider  it  a  contusion  or  interstitial  laceration  of 
brain  substance. 

As  the  appearances  of  a  man  stunned  by  a  blow  are 
very  alarming  *o  those  not  familiar  with  the  march  of 
such  lesions,  those  interested  in  the  injured  man  are 
always  clamorous  for  active  interference,  and  it  is 
with  difficulty  that  the  surgeon  can  free  himself  from 
the  urgent  solicitations  of  friends  who  believe  that, 
unless  prompt  means  are  used,  the  accident  must  termi- 
nate fatally.  The  surgeon,  under  such  circumstances, 
requires  all  of  his  presence  of  mind  to  resist  the  im- 
portunities of  those  who  are  urgent  with  their  advice, 
and  with  firmness  should  strictly  pursue  the  non-inter- 
ference plan  of  treatment. 

The  course  which  rational  surgery  now  recom- 
mends is  to  lay  the  patient  horizontally,  with  his 
head,  perhaps,  a  little  lower  than  his  body,  so  that 
the  brain  may  have  the  benefit  of  gravitation  to  assist 
in  its  supply  of  blood.  He  is  wrapped  in  warm  blank- 
ets, bottles  containing  hot  water  are  placed  around 
bis  body,  and  >\vy  frictions,  with  or  without  mustard, 
used  upon  the  extremities  to  excite  the  re-establish- 
ment of  the  circulation  ;  but  beyond  this  th< 
should  not  interfere.  In  an  ordinary  case  of  cona 
the  safest  pro*  !  ists  in  doing  as  little  as  possible. 

The  indiscriminate  use  oj  stimuli  on  the  one  hand,  or 


276  TREATMENT    OP   CONCl  38ION. 

bloodletting  on  the  other,  are  to  be  especially  and  stu- 
diously avoid,. I. 

Only  a  few  years  since  bleeding  was  the  practice  in 
stunning,  and  the  amount  of  mischief  done  by  this 
universal  mania  for  bloodletting  was  often  irrepa- 
rable. We  might  as  well  Meed  in  a  tainting  fit  and 
expect  good  results.  We  find,  as  in  syncope,  that  the 
heart  scarcely  pulsates;  and  so  little  blood  is  driven 
to  the  surface  that  it  is  pale  and  cold.  A  similar 
condition  exists  in  the  brain,  where  so  little  blood  cir- 
culates that,  from  want  of  this  natural  stimulus,  its 
functions  are  temporaril}*  suspended.  Were  it  possible 
to  draw  away  much  blood  from  this  organ,  the  cessa* 
tion  of  the  nervous  functions  would  become  perma- 
nent. 

Modern  surgery,  in  studying  the  natural  history 
of  diseases  and  injuries,  perceives  now,  what  it  should 
long  since  have  recognized,  that  nature,  in  her  desire 
to  harbor  the  circulating  fluid,  tries  to  put  a  safeguard 
against  the  rashness  of  surgeons,  by  shutting  up  the 
bulk  of  this  living,  precious  fluid  in  the  inner  recesses 
of  the  body,  where  it  can  not  be  easily  despoiled.  On 
account  of  this  change  in  practice,  we  now  seldom 
hear  of  deaths  from  concussion,  which  was  compara- 
tively of  common  occurrence  a  few  years  back. 

As  regards  stimulation,  we  must  also  desist  as  long 
as  it  is  possible,  and  give  it  with  a  most  cautious, 
sparing  hand,  only  when  its  administration  becomes 
compulsory.  Remember  that  the  degree  and  dura- 
tion of  shock  depends  upon  the  extent  of  injury  which 
the  brain  has  received,  and  that  nature,  always  the 
most  skilful  physician,  accepts  this  concussion  as  a 
safeguard  to  prevent  further  mischief.  How  are  we 
to  know  that  the  brain  has  not  sustained  severe 
injury,  extensive  bruising  or  laceration,  with  more  or 


TREATMENT    OF    CONCUSSION.  277 

less  extensive  division  of  blood-vessols;  and  that  this  ex- 
treme depression  of  the  system,  with  consecutive  con- 
trol of  the  heart's  action,  is  not  especially  indicated 
to  prevent  hemorrhage  within  the  brain  substance, 
and  rapid  death  from  compression  induced  by  extrav- 
asated  blood?  We  know  this,  that  after  severe  in- 
jury to  the  brain,  when,  through  officious  meddling 
and  the  free  use  of  brand}7,  the  symptoms  of  concus- 
sion early  disappear,  violent  reaction  is  induced,  and 
internal  hemorrhage  or  violent  inflammation  soon 
shows  itself;  and  that,  for  the  doubtful  gratification  of 
seeing  the  patient  rapidly  revive,  we  have  the  morti- 
fication of  seeing  him  as  rapidly  destroyed. 

Cases  of  concussion,  absolutely  requiring  stimulants, 
are  but  seldom  met  with  in  practice.  Even  when  of  a 
very  severe  form,  all  that  is  necessary,  in  the  vast 
majority  of  cases,  is  to  apply  warmth  to  the  surface, 
and  to  watch  carefully  the  pulse. 

Should  it  so  happen — but  this  occurs  rarely — that 
the  patient  is  manifestly  in  danger  of  sinking  from 
depression  of  the  circulation,  then  stimulants  must  be 
resorted  to.  As  long  as  the  pulse  does  not  lose  its 
Strength  under  concussion  of  the  brain,  although  the  in- 
sensibility last  for  hours  or  even  days,  desist  from  active 
interference.  After-trouble  will  be  avoided  by  allow- 
ing nature  to  take  its  own  course  unmolested.  When, 
from  the  great  and  long-continued  depression,  stimuli 
are  called  for  to  prevent  threatening  dissolution,  their 
effects  should  be  carefully  watched,  and,  as  soon  as 
reaction  is  apparent,  with  an  improving  pulse,  at  once 
desist  from  the  further  use  of  stimuli.  As  is  the  state 
of  depression,  so  will  he  the  state  of  reaction.  When 
the  depression  is  extreme,  the  reaction  will  in  time  be 
correspondingly  excessive,  and  especially  so  if  stimuli 
have  been  freely  administered 


278  COMPRESSION 

When  the  patient,  has  recovered  from  the  state  of 
insensibility,  ho  should  be  kept  perfectly  quiet;  ex- 
oitement  of  every  kind  Bhould  be  carefully  avoided. 
The  diet  should  be  simple,  the  head  kept  cool,  and  any 

tendency  to  constipation  corrected.  Beyond  this  no 
treatment  is  required  until  expressly  called  for  by 
excessive  reaction,  accompanied  with  symptoms  of 
congestion  or  inflammation  of  the  brain.  The  pre- 
cautionary bleeding,  with  repeated  doses  of  calomel, 
to  ward  off  symptoms  which,  in  far  the  majority  of 
cases,  would  not  have  occurred,  was  the  routine  prac- 
tice of  the  old  school,  and  can  not  be  too  severely  con- 
demned. The  complications  which  might  arise  in 
injuries  of  the  head,  after  more  or  less  serious  concus- 
sion, will  be  hereafter  considered. 

COMPRESSION. — Concussion  is  always  simultaneous 
with  the  blow,  and  gradually  decreases,  if  death  does 
not  carry  off  the  patient  at  an  early  period.  Com- 
pression, the  condition  with  which  it  is  often  allied, 
usually  comes  on  some  little  time  after  the  reception 
of  injury,  although  it  may  appear  either  at  the  mo- 
ment, or  may  not  show  itself  tor  days,  or  even  weeks, 
after  the  injury.  The  name  explains  the  lesion  ;  com- 
pression, referring  to  pressure  upon  the  brain,  made 
either  by  a  portion  of  the  skull  or  some  foreign  body 
driven  into  or  upon  the  cerebral  mass;  or  by  an  escape 
of  blood  from  some  torn  vessel,  which,  by  forcing  itself 
into  the  unyielding  skull,  compresses  its  contents  ;  or 
by  an  effusion  of  lymph  or  formation  of  pus,  which 
inflammation  causes  to  bo  deposited  within  the  cavity 
of  the  skull. 

The  symptoms  by  which  this  condition  would  be 
recognized  are  as  follows:  The  patient  lies  in  a  state 
of  coma,  stupor,  or  lethargy — one  side  of  the  body 


SYMPTOMS    OF    COMPRESSION.  279 

being  paralyzed  more  or  less  completely,  both  as  re- 
gards motion  and  sensation.  He  is  dull,  drowsy,  or 
even  insensible;  at  times  answers  mutteringly  when 
rudely  shaken  or  loudly  spoken  to,  but  immediately*' 
afterward  is  again  breathing  slowly,  heavily,  and  la- 
boriously, as  if  in  deep  sleep.  Should  his  face  be  ex- 
amined, the  lips  and  cheek  on  one  side  will  often  bo 
found  to  flap  during  expiration,  producing  a  blowing 
sound,  as  if  smoke  was  being  blown  from  the  mouth 
in  the  act  of  smoking.  'There  is  paralysis  of  that 
side  of  the  body  opposite  to  the  seat  of  injury,  and,  as 
a  necessary  consequence,  the  air  forced  from  the  lung 
in  expiration  puffs  out  that  side  of  the  face  in  which 
the  muscles  have  lost.  tone.  In  attempts  at  speak- 
ing, for  the  same  reason,  the  corner  of  the  mouth  is 
drawn  over  to  the  sound  side.  The  countenance  is 
usually  pale,  cold,  and  ghastly,  although  it  may  be 
flushed  with  a  hot  and  perspiring  skin;  the  eyelids, 
particularly  of  the  paral}Tzed  side,  are  partly  or  com- 
pletely opened,  with  the  pupils  dilated  and  insensiblo 
to  light;  the  pulse  is  slow,  the  heart  acting  under 
great  oppression.  There  is  usually  constipation  with 
torpity  of  the  bowels,  and  as  the  sphincter  muscle  of 
the  rectum  is  paralyzed,  there  exists  usually  involun- 
tary discharges  of  the  feces.  From  want  of  action 
in  the  bladder  the  urine  is  retained,  and,  unless  drawn 
off,  will  decompose  within  the  organ.  If  the  urine  is 
not  drawn  off  with  a  catheter,  the  accumulation  of 
fluid  increases  until  the  bladder  is  either  ruptured, 
causing  a  poisonous  infiltration  into  the  contiguous 
t issues,  or  the  blood  becomes  poisoned  from  the  uIimu-])- 
tion  of  decomposing  urine.  These  symptoms  are  not 
always  equally  marked — their  extent  depending  upon 
the  Buddennesa  and  degree  of  compression.  Unless 
the  causes  of  pressure  be  removed,  the  case  usuallj* 


280  EXAMINATION    OF    HEAD    INJURIES. 

terminates  fatally,  although  cases  are  not  rare  in 
which,  after  days  of  unconsciousness,  reason  has  grad- 
ually been  restored  —  the  accompanying  paralysis 
slowly  disappearing. 

Having  now  explained  the  two  conditions  of  con- 
cussion and  compression,  which  so  commonly  accom- 
pany severe  wounds  of  the  head,  we  are  better  pre- 
pared to  study  this  special  class  of  injuries. 

The  divisions  which  experience  has  proved  of  prac- 
tical utility,  are : 

1.  Injury  to  the  soft  parts  alone,  uncomplicated 
with  injury  to  skull  or  brain. 

2.  Wound  of  soft  parts,  with  simple  fracture  of 
the  skull. 

3.  Wound  with  depressed  fracture  of  the  skull, 
but  without  symptoms  of  compression. 

4.  Compound  depressed  fracture  of  the  skull, 
with  symptoms  of  compression  of  the  brain. 

5  Perforating  wounds  of  the  skull,  complicated 
with  foreign  bodies  in  the  brain. 

From  the  peculiar  formation  of  the  skull  and  the 
resistance  which  it  offers  to  blows,  unless  a  shot  strikes 
it  fairly  at  right  angles,  it  does  not  perforate;  but 
whether  it  be  a  grape,  musket,  or  pistol  ball,  it  flics  off 
at  a  tangent,  and  running  beneath  tho  skin  upward, 
downward,  or  laterally,  escapes.  The  head  has  been 
struck  obliquely  with  even  a  round  shot  without  seri- 
ous injury. 

The  patient  may,  or  may  not,  be  knocked  down  by 
the  blow;  severe  pain  is  felt,  and  a  puffing  up  of  the 
part  instantly  follows.  When  the  hair  is  removed, 
although  there  may  be  no  discoloration  of  the  skin, 
there  is  abundant  evidence  of  subcutaneous  lesion, 
which  will  soon  develop  inflammation  and  suppura- 
tion in  the  scalp      Tho  severity  of  the  blow  upon  the 


SIMPLE    I1KAD    WOUND.  281 

head  may  have  knocked  the  patient  senseless,  and  in 
this  condition  he  is  found  by  the  litter-carriers. 

The  transportation  of  head  injuries  requires  great 
care,  and  the  best  transports  should  be  devoted  to  this 
service.  When  the  patient  ai-rives  at  the  field  infirm- 
ary, where  he  should  be  kept  for  treatment  and  not 
sent  off"  to  a  general  hospital,  he  is  laid  down,  with  the 
bead  low,  until  he  recovers  himself.  The  restoration 
is  left  to  nature;  cold  water  may  be  dashed  into  the  face, 
but  all  stimulation  should  be  avoided  unless  the  pulse 
is  found  to  flag,  when  a  little  brandy  may  be  cautiously 
given.  The  surgeon  takes  advantage  of  the  insensi- 
bility of  the  patient,  shaves  the  head  at  the  point  of 
injury,  and  gives  the  wound  a  thorough  examination. 
Using  always  the  finger  as  a  probe,  he  explores  the  track 
of  the  ball,  examining  the  condition  of  the  skull  to  find 
out  whether  it  has  been  exposed,  and  whether,  simply 
grooved  by  the  ball,  the  injury  involving  the  outer 
tablet  only,  or  whether  the  skull  is  broken  through. 
When  reaction  has  taken  place  and  tho  patient  is  re- 
stored to  consciousness,  should  the  wound  have  been  a 
simple  one  of  the  soft  parts,  the  cold  water  dressing  is 
all  that  will  be  required,  and  should  be  applied  accord- 
ing to  general  principles.  The  thin,  wet  compress, 
covered  with  an  oiled  or  waxed  cloth,  should  cover  the 
wound  and  head  for  some  distance  around  the  injury; 
and  instead  of  tying  these  in  place  by  the  roll  of  band- 
age, the  better  plan  for  keeping  on  the  dressing  is  to 
adopt  the  head-net  of  the  Prussian  medical  service.  It 
is  a  round  piece  of  coarse  netting,  made  of  cotton 
yarn  ;  a  string,  from  either  side,  ties  under  the  chin 
to  keep  the  dressing  on,  and  a  drawing-string  running 
around  the  net,  like  a  purse-string,  attaches  it  securely 
to  the  head  around  the  temples.  This  is  an  admirable 
x 


282  BiMPLk  OsAn  woi  ND 

dressing  for  all  head  injuries,  which  require  light,  cool, 
and  efficient  applications. 

A  very  useful,  although  not  so  eleganl  a  bandage,  la 
made  from  a  piece  of  soft  cloth,  twelve  to  fourteen 
inches  wide,  and  from  twenty-five  to  thirty  inches  .long. 
This  is  slit,  from  each  end,  into  three  unequal  parts, 
leaving  :i  wide  bandage  between  two  narrow  ones — the 
three  slits,  of  either  end,  being  interrupted  in  the  middle 
of  the  bandage  bv  a  bridge,  four  inches  wide,  where  tin- 
cloth  has  not  been  torn.  In  its  application,  place  the 
centre  of  this  three-tailed  bandage  over  the  crown  of 
the  head,  encircling  the  temples  from  behind  forward  by 
the  two  posterior  ends,  and  in  the  same  manner  from 
before  backwai'd  by  the  two  anterior  ends  of  small 
bandage.  The  centre  ends  can  either  be  tied  under 
the  chin  or  can  be  carried  hack  over  the  head.  If  the 
lateral  bands  secure  it  sufficiently,  the  centre  ends 
maybe  cutoff  on  a  level  with  the  temples,  and  pinned 
to  the  lateral  bands.  When  firmly  secured  around 
the  head,  the  whole  completes  a  "bonet  de  nuit"  which 
will  retain  securely  an}-  applications  required  in  the 
treatment  of  head  injuries. 

Should  the  soft  parts  have  been  much  bruised,  the 
ice  bladder,  or  continuous  application  of  cold  water. 
may  be  required  to  keep  down  excessive  suppuration. 
To  prevent  mischief,  and  to  avoid  those  complications 
paused  by  irritation  or  inflammation  of  the  brain,  all 
injuries  of  the  head  demand  rest  and  quiet,  avoidance 
of  stimulants,  and  abstemious  diet.  By  adopting  this 
course  in  uncomplicated  wounds,  whether  gunshot  or 
sabre,  a  speedy  cure  is  usually  obtained. 

When  free  hemorrhage  occurs  in  connection  with 
wounds  of  the  head,  and  evidently  from  an  artery  of 
the  scalp,  it  is  seldom  necessary  to  apply  a  ligature, 


TREATMENT    OF    FRACTURED    SKULL.  288 

as  pressure  exercised  upon  the  skull  will  readily 
check  the  bleeding.  Effusions  of  blood  under  the  skin 
should  not  be  instrumen  tally  interfered  with  ;  incisions 
arc  not  required.  If  tbe  effusions  are  allowed  to  re- 
main excluded  from  air,  the  cold  water  dressing,  ren- 
dered stimulating  by  the  addition  of  tincture  of  arnica, 
will  cause  their  rapid  absorption.  If  the  skin  is  punct- 
ured and  air  admitted,  suppuration  will  surely  ensuo. 
Should  suppuration  occur,  and  especially  erysipelatous 
inflammation,  which  so  frequently  accompanies  injuries 
of  the  seal]),  as  soon  as  pus  can  be  clearly  detected, 
let  it  out  by  a  small  incision.  If  this  operation  be  not 
attended  to  at  the  proper  time,  the  pent-up  pus  will 
separate  the  periosteum  from  the  skull  and  cause. 
perhaps,  a  necrosis  of  tbe  bones.  Chronic  disease  of 
the  skull  is  often  induced  by  a  disregard  of  the  fore- 
going rule.  When  suppuration  has  been  well  estab- 
lisbed.  an  oiled  cloth  is  substituted  for  Avator  dressings 
by  many  surgeons,  altbough  the  growing  disposition 
is  to  continue  the  wet  cloth,  to  be  renewed  as  often 
as  cleanliness  requires,  until  cicatrization  is  completed. 
When  the  skull  has  been  fractured  by  a  ball,  sabre 
blow,  or  fragment  of  shell,  the  treatment  should  in  no 
material  respect  differ  from  tbe  course  pursued  in 
simple  seal])  wounds.  A  simple  or  compound  fracture 
of  the  skull,  uncomplicated  with  injury  to  the  brain  or 
its  meninges',  should  be  managed  according  to  the 
ordinary  principles  of  surgery — remembering  always, 
however,  that  the  brain  is  in  near  proximity,  and  may 
have  been  injured,  although  no  symptoms  are  present 
for  detecting  such  a  lesion.  If  the  patient  is  insensible, 
we  adopt  the  means  already  recommended  for  remov* 
ing  shock,  viz:  place  the  body  in  a  horizontal  posture, 
ani  leave  the  ease  pretty  much  to  nature — avoiding 
everything   tending   to    internal    stimulation.      While 


J 


284  TREATMENT    OF    i'RACTURKD    SKULL. 

insensible,  we  examine  the  wound  thoroughly,  using 
the  finger  as  a  probe;  and  if  any  Loose  spicule  of  bone 
or  foreign  body  be  felt  quite  free  in  the  wound  and 
unconnected  with  the  soft  parts,  they  should  be 
removed.  If  attached,  they  should  be  left  to  escape 
after  suppuration  is  established.  On  rare  occasions  a 
ball  may  be  found  embedded  in  the  diploe  without  hav- 
ing broken,  to  any  extent,  the  inner  tablet.  If  firmly 
embedded,  the  easiest  mode  of  removal,  with  least 
damage  to  the  skull,  is  to  cut  through  the  outer  tablet 
with  the  trephine. 

Fractures  caused  by  balls  are  usually  distinctly 
limited  to  the  portion  struck,  and  seldom  ramify  as 
do  fractures  from  diffused  blows,  such  as  those  from 
large  fragments  of  shell,  etc.  It  is  this  concentration 
of  the  force  within  a  small  compass  which  renders 
gunshot  injuries  of  the  head  so  serious. 

When  we  are  satished,  from  a  careful  examination 
of  the  condition  of  the  bones,  that  they  remain  in 
their  normal  position  without  depression,  no  instru- 
mental interference  should  be  attempted.  As  soon  as 
the  patient  has  re\  ived.  and  the  symptoms  of  concus- 
sion or  shock  have  passed  off,  the  cold  water  or  ice 
treatment  should  be  at  once  instituted.  Should  there 
have  been  but  little  shock  from  the  injury,  the  head 
should  be  shaved  and  wet  applications  should* be  at 
once  applied.  This  treatment  might  be  commenced 
even  on  the  battle-field.  Such  cases  are  always  in- 
juriously affected  by  a  long,  tedious  transportation, 
and  therefore  are  included  among  those  cases  which 
should  be  treated  upon  the  battle-field,  or  at  some  farm* 
house  in  the  immediate  vicinity  of  the  field  infirmary. 

When  the  patient  is  put  to  bed  (which  should  be 
as  soon  as  possible  after  reaction  has  taken  place,  for 
early   treatment  is,   at  this  stage,  all-important)   his 


TREATMENT    OF    CEREBRAL    INFLAMMATION.        285 

head  and  shoulders  should  be  elevated,  and  quiet,  with 
absolute  rest,  should  be  enjoined.  The  room  should 
be  kept  dark,  and  all  stimuli,  including  light  and  noise, 
should  be,  if  possible,  avoided.  The  bowels  should 
bo  freely  opened  by  a  saline,  mercurial,  or  aloetic 
cathartic,  and  for  a  few  daj^s  abstemious  diet  pre- 
scribed. These  precautions  are  necessary  to  prevent 
irritation  of  the  brain,  with  subsequent  congestion,  in- 
flammation, and  effusion.  If  the  patient  appears  irri- 
table and  peevish,  without  much  heat  of  head  or  fulness 
of  pulSe,  give  opium  to  quiet  him. 

The  case  should  be  watched  with  care,  and  if  symp- 
toms of  congestion  of  the  brain  threaten,  with  injec- 
tion of  the  face,  red  eyes,  hot  skin,  forcible  throbbing 
of  the  carotids,  increasing  headache,  with  an  early 
tendency  to  delirium,  the  patient  might  be  at  once 
bled.  The  head  should  be  shaved,  and  an  ice  bladder 
or  cloths  wet  with  cold  water,  and  frequently  renewed, 
be  assiduously  applied  over  the  entire  scalp.  The  in- 
testines should  be  freely  acted  upon,  so  as  to  obtain 
therevulsive  effect  of  the  purgative  upon  the  brain,  and. 
for  a  similar  reason,  mustard  should  be  applied  to  the 
tegs  and  thighs.  Should  relief  not  be  promptly  obtain- 
ed, leeches  or  cups  might  be  applied  to  the  temple  or  the 
scalp  behind  the  ears,  or  a  large  blister  put  upon  the 
back  of  the  neck,  extending  down  between  the  shoul- 
ders. Calomel  was  formerly  the  universal  prescrip- 
tion for  threatening  cerebral  inflammation.  Salivation 
was  induced  as  early  as  possible,  and  when  t  lie  system 
wal  brought  under  its  influence  the  patient  was  con- 
sidered comparatively  sate.  In  modern  surgery  calo- 
mel has  lost  its  high  position,  and  the  dependence 
Upon  its  salivating  powers  is  annually  diminishing. 
.Many  still  use  it,  but  not  with  the  confidence  of  for- 
mer times. 


286  ABSCESS    O.N    THE    BRAIN. 

Should  this  threatened  inflammation  not  subsidy 
under  this  course  of  treatment,  but,  after  a  period  of 
high  febrile  excitement,  the  delirium  becomes  merged 
into  stupor,  with  noisy  breathing,  dilated  pupils,  slow, 
labored  pulse,  relaxed  sphincters,  and  paralysis,  the 
case  indicates  compression  from  effusions  within  or 
upon  the  brain,  and  chances  for  life  become  very 
doubtful.  Perhaps  a  thick  layer  of  lymph  may  have 
formed  upon  the  cerebral  surface,  or  a  quantity  of 
serous  fluid  collected  in  the  ventricles,  or  a  circum- 
scribed or  diffused  abscess  may  have  collected  "m  the 
substance  or  upon  the  surface  of  the  brain.  This 
lymphy  effusion  or  collection  of  pus  sometimes  covers 
the  en  tire  surface  of  one  or  both  hemispheres.  In 
such  cases  the  arachnoidal  membrane  appears  to  he  the 
one  chiefly  inflamed.  It  is  thickened,  semi-opaque, 
reddened  in  patches,  and  adherent  to  the  brain  surface 
as  well  as  to  the  reflected  lining  of  the  dura  mater  by 
bands  of  newly  deposited  lymph.  The  pia  mater  and 
brain  substance  is  also  highly  injected. 

If,  -with  the  occurrence  of  these  symptoms,  the  pa- 
tient be  seized  with  chills,  the  scalp  wound  becoming 
dry  and  the  tissues  puffy,  or  a  collection  forms  under 
the  periosteum,  lifting  this  membrane  from  the  bones, 
which,  when  exposed,  appear  dry  and  yellow,  it 
would  indicate,  in  many  instances,  a  circumscribed 
collection  of  pus  within  the  skull.  These  symptoms 
might  be,  but  wry  rarely  are,  relieved  by  the  use  of 
the  trephine,  and.  as  a  general  rule,  the  case  progresses 
steadily  to  a  fatal  termination.  I'nless  an  external 
abscess,  with  the  characteristic  puffy  scalp,  defines 
the  collection  of  effusions  within,  the  trephine  should 
not  be  used,  as  there  would  be  little  probability  of 
perforating  the  skull  in  the  vicinity  of  the  collection. 
It  often  happens,  after  trephining,  that  these  supposed 


HEMORRHAGE    ON    THE    BRAIN.  287 

collections  have  not  been  found,  and  it  is  only  after  the 
irritating  effects  of  the  operation  that  the  secretion 
of  pus  has  been  established.  When  air  is  freely  ad- 
mitted to  the  meninges  suppuration  is  highly  proba- 
ble, while,  without  the  operation,  the  effusionsof  blood, 
lymph,  etc.,  are  known,  in  many  instances,  to  have 
been  absorbed — the  patient  recovering  after  remain- 
ing insensible,  in  one  case,  us  long  as  twenty-^e  days. 

Cole,  in  his  Military  Surgery,  mentions  cases  of 
fracture  of  the  skull  from  ball,  without  the -skin  being- 
torn.  Such  cases  are  very  difficult  of  diagnosis.  Unless 
the  bones  are  much  displaced,  as  they  were  in  one  of 
his  cases,  the  condition  would  scarcely  be  suspected. 
Such  injuries  must  be  treated  under  the  antiphlogistic 
expectant  plan.  Await  symptoms  of  compression  before, 
active  surgical  interference  is  instituted,  and  we  will  never 
regret  it. 

There  arc  a  series  of  cases  in  which  injury  to  the 
skull  is  complicated  with  internal  bleeding.  The  in- 
sensibility which  seized  the  patient  at  the  moment  of 
injury  will  pass  off,  and  the  consciousness  will  be  re- 
gained, but  only  for  a  time.  The  patienj,  after  a 
longer  or  shorter  interval,  feels  heavy  and  dull,  and 
indisposed  to  exertion  ;  until,  finally,  a  strong  dispo- 
sition to  sleep  comes  over  him,  which,  deepening  into 
coma,  ends  in  all  the  symptoms  of  well  marked  com- 
pression. This  is  an  instance  in  which  the  surgeons  of 
twenty  years  since  would  have  trephined,  as  the  only 
chance  of  saving  the  patient  ;  and  should  the  collec- 
tion of  blood  not  have  been  found  under  the  lirs!  per- 
foration in  the  skull  a  second,  third,  etc.,  would  have 
been  made  in  search  of  the  extravasated  fluid  until,  in 
some  recorded  cases  of  a  former  surgery,  the  head  had 
literally  been  sieved   by  twenty  orifices. 

Now   we  would   lay   down   an  equally    broad   rule, 


288  HEMORRHAGE    ON    THE    BRAIN. 

that  his  chances  for  recovery  are  increased  by  avoid- 
ing the  trephine.  Pursue  a  rigidly  antiphlogistic 
course.  Free  venesection,  when  assisted  by  ice  blad- 
ders to  the  entire  scalp,  will  stop  further  loss  of  blood. 
Reduce  the  action  of  the  heart  by  veratrum,  gelsemi- 
nura,  or  digitalis,  and  permit  the  effused  blood  to  clot, 
so  as  to  close  the  openings  in  the  torn  blood-vessels. 
Then,  bjjkfrce  purgation,  act  upon  the  bowels,  both  for 
a  derivative  effect  and  to  promote  the  absorption  of 
the  effusion.  If  you  can  stop  the  further  escape  of 
blood,  that- which  has  been  effused  will  gradually  be 
removed,  and  the  symptoms  of  compression  will  as 
gradually  pass  off,  after  having  continued,  perhaps, 
for  days,  or  even  weeks.  Trephine  such  a  patient, 
and  what  certainty  have  we  that  the  point  where 
hemorrhage  has  taken  place  will  be  unmasked,  or 
that  the  blood  is  still  fluid  and  can  be  removed — both 
very  improbable  results.  Blood-vessels  may  have 
given  way  at  any  other  portion  of  the  brain  than  at 
the  portion  corresponding  to  the  point  where  the 
skull  is  injured.  The  recoil  of  the  contents  of  the 
skull  from  the  blow  may  have  ruptured  vessels  dia- 
metrically opposite  to  the  injured  point.  Autopsies 
not  unusually  reveal  such  conditions. 

In  gunshot  wounds  from  musket-balls  the  fracture 
of  the  bones  of  the  skull  is  usually  circumscribed,  and 
when  situated  over  the  course  of  a  large  meningeal  ves- 
sel, and  these  symptoms  of  internal  hemorrhage  super- 
vene, there  will  be  a  probability  that  the  injured 
blood-vessel  is  in  the  immediate  vicinity  of  the  wound. 
Usually,  in  such  cases,  the  hemorrhage  would  show  it- 
self by  the  escape  of  blood  externally.  Under  such 
circumstances  it  would  be  necessary  to  remove  the 
portions  of  broken  bone,  either  by  the  trephine,  saw,  or 
forceps;  and  the  bleeding  vessel,  if  seen,  should  be  se- 


FRACTURES,    WITH    DEPRESSION.  289 

cared  by  ligation  or  by  the  pressure  of  a  torsion  forceps. 
Those  conditions,  however,  rarely  exist,  and  the  location 
of  hemorrhage  is  exceedingly  doubtful.  The  operation 
of  trephining  is  always  very  serious  per  se,  and  is,  in 
many  instances,  sufficient  of  itself  to  cause  cerebral 
or  meningeal  inflammation,  which  will  nearly  always 
terminate  fatally.  The  operation  is  often  as  serious 
as  the  condition  for  which  it  is  used,  and,  although 
the  patient  might  recover  from  either,  he  succumbs 
under  the  combination.  Experience  and  autopsies 
have  shown  us  many  cases  of  extensive  intra-eranial 
hemorrhage,  which  have  been  unaccompanied  by  symp- 
toms denoting  such  an  accident;  and  the  evidences  of 
such  have  only  been  found  when  the  patient,  recover- 
ing from  his  head  injury,  had,  at  some  subsequent 
period,  fallen  a  victim  to  a  totally  foreign  disease. 
Had  such  a  condition  been  suspected,  and  the  surgeon 
used  his  instruments  with  the  object  of  allowing  the 
effused  blood  to  escape,  most  probably  an  autopsy,  at 
a  much  earlier  day,  would  have  revealed  the  condi- 
tion. 

The  third  variety  of  gunshot  injury  of  the  head,  with 
depressioti  of  the  skull,  belongs  to  a  more  serious  class 
of  wounds.  The  complication  is  detected  without 
difficulty  by  examining  the  depth  of  the  wound  with 
the  finger,  when  the  sinking  of  the  bones  is  felt,  the 
extent  of  injury  defined,  and  the  oonditian  of  the  de- 
pressed portion,  whether  en  masse  or  spiculated,  deter- 
mined. The  depressed  portion  of  bone,  although 
usually  accompanied  with  symptoms  of  compression 
or  pressure  upon  the  brain,  may  have  no  such  compli- 
cation. The  mind  may  remain  perfectly  clear,  and 
the  patient  enjoy  tho  voluntary  control  of  all  of  his 
limbs.  In  certain  cases  of  depressed  bone,  however, 
there  exists  paralysis*of  the  limits  on  the  opposite  side 

Y 


290  FRACTURES,    WITH    DEPRESSION. 

of  the  body  to  thai  side  of  the  head  injured.  This 
class  of  fractures  of  the  head  are  considered  very  dan- 
gerous, inasmuch  as  the  depressed  fragments  of  the 

skull — -which  usually  has  its  inner  tablel  much  more 
extensively  broken  and  displaced  than  the  outer  — 
may  have  been  driven  through  the  membranes  into 
the  Bubstance  of  the  brain,  and  there  establish  such  a 
train  of  inflammatory  symptoms  as  will  destroy  lifo. 
A  very  large  number,  however,  recover  perfectly  from 
such  injuries. 

In  simple  fractures  of  the  skull,  even  with  depres- 
sion of  the  fragments,  but  without  a  wound  of  the 
soft  parts,  the  rule  to  be  followed  is  to  avoid  the  use 
of  instruments,  and  exclude  air  from  coming  in  '-.in- 
tact with  the  broken  bones  through  an  incision  made 
by  the  surgeon.  Eveu  when  symptoms  of  compres- 
sion accompany  the  displacement,  it  is  thought  expe- 
dient, by  many  Burgeons  Of  large  experience,  not  to 
operate,  in  gunshot  fractures  of  the  skull  the  case  is 
somewhat  different,  as  there  is  always  a  wound  con- 
nected directly  with  the  fracture.  Still,  as  a  rule,  we 
must  avoid  meddling  with  tho  parts.  If,  upon  exami- 
nation, many  spicuhe  oi  bone  are  found  detached  from 
their  connections,  and  lying  loosely  in  the  wound,  t  hey 
should  be  carefully  removed.  This  is  done  as  soon 
after  the  injury  as  possible,  and  often  while  the  pa 
tient  is  suffering  from  compression.  Should  tho  symp- 
toms of  concussion  have  passed  off,  and  no  indications 
exist  of  injurious  pressure  upon  tho  brain,  nor  of 
loose  fragments  of  bone  in  the  wound,  surgeons  of 
experience  recommend  that  the  ease  be  treated  in 
every  respect  as  if  no  depressed  fragments  existed. 
In  such  cases,  unless  we  can  clearly  determine  that 
the  bone  is  very  much  spiculated,  and  that  sharp  frag- 
ments are  probably  piercing  the  meninges,  wo  should 


TREATMENT   OF    HEAP    INJURIES.  201 

avoid  all  instrumental  interference,  oven  to  dilating 
the  wound,  for  the  purpose  of  facilitating  a  more 
accurate  diagnosis. 

A  rule  which  can  not  he  impressed  upon  us  too 
early  is,  that  we  should  never  be  anxious  to  see  the 
symptoms  of  concussion  rapidly  disappear  in  such 
cases;  let  nature  abide  her  time ;  watch  the  case,  and 
see  that  the  patient  suffers  no  detriment.  Examine 
frequently  the  pulse,  but  not  the  head,  and  as  long  as  it 
sustains  itself,  everything  is  working  to  the  advantage  of 
the  wounded.  With  a  rapid  reaction,  torn  blood-ves- 
Bels  may  not  have  had  time  to  become  plugged  up, 
and  internal  hemorrhage,  which  is  always  serious, 
might  ensue.  Lay  the  patient  in  a  horizontal  posi- 
tion, cover  him  with  blankets,  and,  if  required,  use 
external  warmth.  Internal  stimulation  would  not  be 
required  in  the  majority  of  cases.  It  is  only  when 
the  pulse  evidently  flags  that  it  should  be  used.  As 
soon  as  the  pulse  indicates  an  improvement,  we  com- 
mence cold  applications  to  the  scalp,  which  should  be 
continuously  and  assiduously  applied.  When  inflam- 
mation of  the  meninges,  which  may  make  its  appear- 
ance  about  the  fifth  day,  threatens,  revulsives,  acting 
by  derivation  to  the  intestines,  as  recommended  in  the 
treatment  of  simple  fractures,  with  ice  or  cold  water 
to  the  head,  are  the  remedies  upon  which  most  re- 
liance is  to  be  placed.  When  severe  headache  or 
exciting  delirium  is  present,  cold  water  may  be  fre- 
quently poured  over  the  head  in  douches  with  decided 
benefit.  Free  purgation  is  not  desirable,  as  the  fre- 
quent change  <>f  position  would  be  injurious  to  the 
patient.  Should  the  integuments  and  pericranium 
inflame,  with  much  swelling,  pain,  tension,  and  with 
febrile  reaction,  bring  on  the  formation  of  pus,  or  if 
the  wound  docs   not  give  ready  exit  to  the  purulent 


292  IKlATMhNT    OF    DEPRESSED    BONE. 

secretion,  a  free  incision  must  be  made  to  releasi 
pent-up  fluids. 

Surgeons  are  now  becoming  familar  witb  the  Facl 
that  considerable  depressioi  mayexisl  in  the  external 
tablel  of  iIk'  skull  without  the  internal  having  been 
fractured — the  external  layer  being  driven  into  and 
condensed  within  the  <  1  i  i >  1  <  »* ■ .  Also,  that  both  tablets 
may  be  depressed,  compressing  the  brain,  without 
causing  harm  at  any  subsequent  period.  Observation 
h;ts  multiplied  those  cases  to  such  an  extent  as  to  mod? 
ify  the  entire  treatment  of  head  injuries.  Although 
the  crania!  cavity  is  filled  with  brain,  its  contents  are 
continually  undergoing  changes,  from  the  excessive 
vascularity  of  the  brain  substance,  ami  also  from  the 
free  communication  which  exists  between  the  fluid, 
filling  the  ventricles  ami  the  venous  plexi  which 
abound  in  the  brain.  By  diminishing  tin'  blood  and 
water  in  the  brain,  accommodation  can  lie  made  for 
the  depress*  d  hone. 

As  a  general  rule,  in  gunshot  wounds  of  the  skull, 
with  depression  of  fragments,  no  remarkable  symp- 
toms exhibit  themselves  until  there  is  a  determination 
of  blood  to  the  head  from  reaction,  brought  on  by 
mental  or  bodily  excitement.  Rational  practice  would 
had  us  to  combat  the  tendency  to  congestion  by  rest} 
quiet,  cold,  and  revulsives,  rather  than  by  the  tre- 
phine, which  experience  has  shown  to  he  unprofitable. 

Opium  is  now  used  with  much  greater  freedom  in  the 
treatment  of  injuries  of  the  heal  than  formerly;  and, 
when  administered  with  discretion,  will,  to  a  certain 
extent,  take  the  place  of  trephining.  Whenever  the 
patient  is  restless,  sleepless,  and  irritable,  with  deli- 
rium, should  the  face  not  be  red,  nor  head  hot,  opium, 
or  some  of  its  preparations,  can  be  used  with  safety 

and  hem-tit 


TREATMENT  OP  PERFORATED  W0UND8  OP  HEAD.     293 

Those  Burgeons  wlio  arc  opposed  to  the  use  of  in- 
struments in  cases  of  compound  fracture  of  the  skull 
have  been  led,  hy  experience,  to  refrain  from  removing 
the  spicules  until  suppuration  is  well  established. 

In  gunshot  wounds  of  the  head  this  will  be  found 
the  safest  course  to  pursue,  and  is  in  opposition  to  the 
rule  laid  down  in  gunshot  rounds  of  the  extremities, 
where  it  was  recommended  to  removo  all  loose  por- 
tions of  the  bone. 

When  granulations  commence  to  form,  those  por- 
tions of  bone  which  can  not  be  saved  will  gradually 
become  detached,  and  will  escape.  A  tendency  ,to 
bleeding  in  the  granulations  of  such  a  wound  is  an  in- 
dication that  the  fragments  of  bone  have  become  loose, 
and  are  ready  to  be  removed.  This  symptom,  which 
is  a  valuable  one,  must  be  noted. 

The  fourth  variety  of  injury  to  the  head,  and  by  far  the 
most  serious,  is  that  in  which  a  compound  fracture,  with 
depressed  fragments,  is  connected  with  symptoms  of  com- 
pression and  paralysis.  This  is  the  only  variety  of 
complicated  head  wounds  in  which  surgeons  now  con- 
sider instrumental  interference  justifiable;  and  even  in 
this  instance,  although  no  doifbt  exists  that,  in  some 
cases,  immediate  relief  has  followed  the  lifting  of  the 
depressed  bone,  the  propriety  of  trephining,  as  a  rule, 
is  doubted  by  many  army  surgeons  of  large  expe- 
rience. The  successful  treatment  of  such  injuries  will 
depend  more  upon  the  condition  of  the  brain  and 
membranes  than  merely  upon  the  depression.  Should 
these  be  lacerated,  or  in  any  way  injured,  inflamma- 
tion will  probably  show  itself,  sooner  or  later.  The 
operation  of  trephining,  under  such  circumstances, 
would  increase  the  local  irritation,  expose  the  injured 
tissue-  to  injurious  atmospheric  influences,  and  hasten 
on  a  violent,  and  usually  fatal,  inflammation. 


294  TREPHINING    INJURIES    OFTEN    FATAL. 

If  the  brain  and  membranes  be  not  injured,  expe- 
rience teaches  that  the  brain  will  soon  become  accus- 
tomed to  the   pressure;   and,  although    insensibility 

may  continue  for  hours,  days,  oi .  as  in  many  instances 
of  ultimate  recovery,  for  weeks,  the  symptoms  of  com* 
prossion  and  paralysis  will  gradually  pass  off.  By  not 
using  instruments,  the  Burgeon  has  the  satisfaction  of 
knowing  that  he  has  not  increased  the  local  trouble 
by  a  serious  operation.  When  the  depressed  bone  is 
not  raised,  the  removal  of  the  symptoms  of  com- 
pression, being  very  gradual,  excessive  reaction  is 
not  likely  to  follow;  and  as  no  air  has  been  admit- 
ted to  the  effusions  beneath  the  skull,  the  probability 
of  suppuration  will  be  much  diminished.  When 
effusions  have  taken  place,  the  depressed  bone  arts 
as  a  covering,  excluding  air,  with  its  injurious  chem- 
ical influences;  and  autopsies  at  some  distant  period 
show  that  fluids,  uncontaminated  by  decomposition, 
can  be  absorbed.  When  the  skull  is  opened,  and  the 
Tree  admission  of  air  is  permitted,  suppuration,  with, 
perhaps,  pyemia,  is  prone  to  occur. 

Stromyer,  who  is  one  of  the  highest  authoritie 
gunshot  wounds  of  the  head,  and  who,  as  surgcou-in- 
chief  of  the  Schles wig-Hols tein  army,  had  cxwy 
facility  for  studying  his  favorite  branch  of  surgery, 
gives  us,  as  the  result  of  hjs  experience,  observation^ 
and  study,  that  the  trephine  can  be  abandoned  in 
military  surgery,  in  a  supplement  to  his  work  on 
Military  Surgery,  recentlj-  published,  he  stales:  "  That 
in  military  surgery  trephining  is  never  needed.  When 
the  ease  is  so  severe  as  to  require  the  trephine  in  gun- 
shot wounds,  the  patient  will  die  in  spite  of  it.''  In 
the  Last  two  campaigns,  in  which  he  had  charge  of  the 
army,  he  has  not  trephined.  Loeffler,  a  distinguished 
surgeon   in   the   Prussian   service,  who  has  published 


TREPHINING    INJURIES    OFTEN    FATAL.  295 

one  of  the  best  books  of  instruction  for  military  sur- 
geons, after  acknowledging  Stronger  as  the  master  in 
all  relating  to  the  treatment  of  gunshot  wounds  of  the 
head,  endorses  his  views  in  opposition  to  trephining. 

McLeod  gives  the  following  as  the  Crimean  experi- 
ence :  "As  to  the  use  of  the  trephine — the  cases  and 
time  for  its  application — less  difference  of  opinion,  I 
believe,  exists  among  the  experienced  army  surgeons 
than  among  civilians;  and  I  think  the  decided  ten- 
dency among  them  is  to  endorse  the  modern  '  treatment 
by  expectancy,'  and  to  avoid  operating  except  in  rare 
cases.  In  this,  1  believe,  they  judge  wisely  ;  for  when 
we  examine  the  question  carefully,  we  find  that  there 
is  not  one  single  indication  for  having  recourse  to 
Operations  which  can  not,  by  the  adduction  of  pertinent 
cases,  be  shown  to  be  often  fallacious."  Hewctt,  in  a 
Series  of  lectures  on  injuries  of  the  head,  published  in 
the  Medical  Times  and  Gazette  for  1859,  which  form 
the  most  complete  treatise  extant  on  the  subject,  is 
equally  adverse  to  the  trephine.  Guthrie,  Cole,  and 
Williamson,  in  their  reports,  equally  confirm  the  dan- 
gers of  the  trephine,  and  the  great  fatality  accom- 
panying its  use. 

The  entire  records  of  the  science  may  be  searched 
in  vain  to  find  a  duplicate  series  of  successful  cases  to 
that  reported  by  Stromyer.  Of  forty-one  cases  of 
fracture,  with  depression  from  gunshot  wounds,  in 
many  of  which  it  was  probable  that  the  brain  and 
membranes  were  injured,  only  seven  died — all  the  rest 
recovered-  In  only  one  case  was  there  any  operative 
interference,  although  si$ns  of  secondary  compression  <ij>- 
1  in  several.  The  antiphlogistic  treatment,  care* 
fully  carried  out,  was  alone  adhered  to. 

No  Burgeon  can  doubt  that  the  operation  of  trephin- 
ing has  cost  many  a  man  his  lite;  and  although  many 


ABE  BRAIN. 

cases  have  recovered  after  the  operation,  it  i>  a  ques- 
tion whether,  in  the  majority  of  cases,  more  rapid 
recovery  would  not  have  been  obtained  without  it. 

When  symptoms  of  compression,  accompanied  with 
paralysis,  and,  finally,  stupor,  ensue  in  the  course  of 

treatment,  continue  the  Steady,  onward  use  of  anti- 
phlogistic remedies.  At  this  juncture  many  Burgeons 
recommend  calomel  pushed  to  salivation,  which  some 
state  to  be  synonymous  with  salvation.  There  is, 
however,  no  unanimity  on  this  head;  the  modern 
practice  is  to  treat  such  eases  without  the  use  of 
mercury. 

At  this  stage  of  the  case,  which  is  one  of  extreme 
gravity,  a  successful  course  of  treatment  can  hardly 
be  expected.  Should  the  symptoms  of  compression 
have  been  preceded  by  one  or  more  severe  chills,  with 
excitement  of  the  pulse,  pain  in  the  head,  divergence 
of  the  eyes,  protrusion  of  the  tongue  to  one  side,  a  dull, 
pricking  sensation  in  the  arm  and  leg  opposite  to  that 
wounded,  we  might  feel  assured  that  pus,  or  some 
effused  fluid,  has  been  thrown  out  upon  the  brain,  and, 
usually,  that  the  substance  of  this  organ  has  heeomo 
more  or  less  softened.  As  such  cases  are  exceedingly 
fatal,  the  operation  of  trephining  is  usually  performed] 
hoping  that  the  collection  of  pus  may  he  found  and 
discharged,  and  that,  by  the  relief  of  pressure,  the 
serious  symptoms  may  ho  also  removed.  Very  rare 
instances  of  such  successes  are  upon  record,  hut  in  by 
far  the  majority  of  eases  the  symptoms  continue  una- 
bated, even  when  the  abscess  has  heen  opene/1. 

The  following  case  is  pertinent  to  the  subject  under 
discussion  : 

Private  I>.  Shumpert,  Company  F,  20th  regiment  S. 
C  V..  aged  eighteen,  was  stunned  by  the  explosion  of 
a  shell  during  the  bombardment  of  Battery  Wagner, 


ABSCESS   ON    BRAIN.  LH.»7 

July  18,  ISO:.  He  soon  revived,  and  was  sent  to  a 
hospital  in  Charleston  on  the  following  day.  Upon 
examination  a  small  shell  wound  was  found  in  the 
scalp  behind  the  left  ear,  but  was,  apparently,  of  a 
very  trivial  character.  He  was  transferred  to  a  hos- 
pital in  Columbia  on  the  23d  of  July,  1863.  The  ex- 
ternal ear  had  been  perforated  by  a  small  fragment  of 
shell,  and,  in  connection  with  sensitiveness  of  the  scalp, 
there  was  contusion  of  the  tissues  behind  the  left  ear. 
Under  the  usual  cold  water  dressing  the  wound  rap- 
idly healed,  the  sensitiveness  disappeared,  and  only  a 
small  orifice  in  the  scalp  behind  the  left  ear  remained 
open — all  swelling  having  subsided. 

Since  his  admission  he  had  been  considered  a  con- 
valescent, and  had  associated  freely  Avith  the  inmates 
of  the  hospital,  lie  was  now  nearly  ready  to  return 
to  his  regiment,  when,  on  the  30th,  he  complained  of 
feeling  his  eyes  filling  with  tears  when  spoken  to, 
which  was  attributed  to  his  anxiety  to  get  home.  On 
the  31st  he  complained  of  great  weakness,  left  eye  suf- 
fused, and  orbicular  muscles  slightly  paralyzed,  with 
inability  to  turn  his  head  to  the  left  side. 

August  1. — He  had  fever,  pulse  one  hundred,  tongue 
coated,  bowels  costive,  spirits  depressed.  As  these  fe- 
brile sj^mptoms  continued,  he  was  treated  for  continued 
fever.  On  the  7th  he  had  a  severe  chill,  which 
Was  repeated  during  the  day,  with  tendency  to  sleep. 
When  roused,  he  complains  of  pain  in  the  back.  The 
chills  appeared  again  on  the  following  day,  with  grad- 
ually increasing  stupor.  As  he  had.  at  DO  time,  com- 
plained of  his  head,  the  presence  of  the  wound  was 
altogether  overlooked.  On  the  !Mh  a  purulent  dis- 
charge was  noticed  from  the  ear,  which  attracted  sus- 
picion to  the  head,  and  suggested  the  probability  of  an 
abscess  upon  the  brain. 


_!'."s  AB8CE88    ON    IlllAIN. 

Coma  being  well  established  by  the  lOthj  and  a 
probe,  passed  into  the  small  wound  behind  the  ear, 
having  come  in  contaot  with  denuded  bone,  ii  wus  de- 
cided i"  dilate  freely  the  wound,  expose  the  hone,  ami, 
should  any  fracture  and  depression  of  fragments  be 
found,  to  trephine.  A.a  the  mastoid  portion  of  the  left 
temporal  was  found  denuded,  with  a  depressed  fragment 
of  skull  at  the  junction  of  this  bone  with  the  ocoipital, 
the  trephine  was  used,  and  several  fragments  of  the 
inner  table,  which  were  Pound  detached,  were  rem ■ 
The  trephine  had  been  applied  directly  over  the  lat- 
eral sinus,  and  the  anterior  edge  of  the  orifice  corres- 
ponded with  the  line  of  attachment  of  the  tentorium 
cerebelli.  No  pus  was  found.  No  amelioration  of 
symptoms  followed  the  operation,  and  the  patient  died 

twelve  hours  alter  it. 

An  autopsy  revealed  a  fracture  of  the  skull,  which 
had  completely  separated  the  squamous  from  the 
petrus  portions  of  the  left  temporal  bone,  the  fissure 
extending  in  front  of  the  ear  to  the  base  of  the  skull. 
Inflammation  had  been  excited  in  the  membranes  aa 
well  as  in  the  substance  of  the  brain  at  the  base  of  the 
skull,  and  a  large  accumulation  of  foetid  pus,  about  feuu 
ounces,  had  collected  in  the  arachnoidal  cavity,  and 
had  so  compressed  the  hemisphere  of  the  brain  that 

there  was  a  space  fully  an  inch  in  depth    between    the 

flattened  hemisphere  and  the  skull — the  pus  covering 
the  entire  surface  of  the  hemisphere  from  the  tentori- 
um cerebelli  to  the  falx  cerebri.  The  base  of  the  brain, 
corresponding  with  the  broken  hone,  was  softened, 
and  of  oreamy  consistency.  Had  the  trephine  been 
placed  one  quarter  of  an  inch  more  anteriorly,  it 
would  have  allowed  the  escape  of  pus,  although  the 
emptying  of  the  abscess  could  not  have  saved  life,  as 
experience  shows  injuries  to  the  base  of  the  braiu, 


FOREIGN    BODIES    IN    BRAIN.  299 

followed  by  inflammation  and  coma,  to  be  always 
fatal.  The  caso  is  of  much  interest  in  many  respects, 
but  more  especially  shows  that  an  injury  of  the  head, 
of  the  most  serious  character,  may  be  inflicted  with- 
out creating  even  a  suspicion  of  its  existence;  and  as 
this  may  frequently  occur,  it  should  teach  us  to  con- 
sider all  cases  of  head  injury  serious. 

When  balls  penetrate  or  perforate  the  cranium,  the 
detached  pieces  of  bone  are  driven  before  the  ball  into 
the  substance  of  the  brain,  leaving  an  orifice  in  the 
skull  larger  than  the  missile  which  made  it.  The 
resistance  which  the  ball  meets  may  change  its  course, 
and,  glancing  from  the  depressed  fragment,  it  takes 
a  different  direction — burying  itself  in  the  brain  at 
some  distance  from  the  piece  of  bone. 

In  by  far  the  majority  of  cases  death  is  instantane- 
ous, or  soon  follows  the  receipt  of  this  injury.  In 
such  cases  it  sometimes  happens  that  the  patient  has 
survived  the  shock,  and  has  been,  to  all  appearances, 
recovering  rapidly,  when  he  is  suddenly  seized  with 
COma,  and  rapidly  dies.  There  are,  nevertheless,  a 
few  exceptions  to  this  rule,  in  which  the  patient, 
recovering  from  the  shock  and  sequela1,  although  he 
may  have  lost  a  quantity  of  brain  substance,  has  car- 
ried the  ball  or  other  missile  within  his  cranium  for 
years.  Eventually  dying  of  some  disease  unconnected 
with  the  head,  an  autopsy  has  revealed  the  ball  em- 
bedded in  the  brain,  and  surrounded  by  a  ma- 
lymph.  Of  ninety  -one  cases  of  ponetrating  and  per- 
forating gunshot  wounds  of  the  head  which  were 
admitted  into  hospital  in  the  Crimea,  all,  without 
option,  proved  fatal. 

When  the  openings  are  examined,  it  will  he  found 

that   the  hole  made  in  the  outer   tablet  is  more  or   less 

smooth,  while  the  orifice  in  the  inner  tablet  is  mnch 


300  FOREIGN    BODIES    IN    BRAIN. 

more  extensively  fractured,  and  usually  much  Bpicu- 
lated.  This  condition  of  the  orifices  is  owing  more  to 
the  direction  of  the  blow  than  from  any  Bupposed  brit" 
tieness  in  the  inner  tablet — for,  ahould  the  ball  traverse 
from  within  outward,  the  reversed  condition  is  ibund. 
It  would  be  folly  to  attempt  the  search  after  such 
foreign  bodies  for  the  purpose  of  removing  them,  as 
such  a  piece  of  meddlesome  surgery  would,  in  by  far 
the  majority  of  cases,  ensure  a  fatal  issue,  whatever 
bope  of  recovery  might  have  been  previously  enter- 
tained.* 

Cole,  in  his  Indian  Reports,  mentions  -'That  there 
arc  many  soldiers  now  doing  duty  in  our  ranks  for 
whom  (having  been  wounded  in  their  heads  during  the 
late  war)  the  medical  oflicers  had  not  the  smallest 
hope;  and  every  military  surgeon,  who  has  had  much 
practice  in  the  field,  has  learned  not  to  despair  so 
long  as  life  remains."  The  thorough  probing  of  such 
wounds  with  a  metallic  probe,  to  satisfy  the  curiosity 
of  a  surgeon,  would  soon  have  destroyed  all  bope, 
with  the  life  of  the  patienl  ;  ami  yet  I  have  seen  ignorant 
and  careless  surgeons  rooting  into  the  brain  with  a 
silver  probe  as  if  they  wore  determined  to  find  a 
foreign  body,  cost  what  it  may.  It  is  needless  to  say 
that  such  practice  is  criminal,  and  in  no  possible  ease 
called  for. 

The  general  treatment  of  SUCh  cases  should  in  no- 
wise differ  from  that  laid  down  for  the  treatment  of 
head  injuries  in  general.  The  symptoms  of  concussion 
and   compression,  which   arc  well   marked  and  always 

*  On  one  occusiun.  by  the  use  of  a  gum  bougie,  Baron  narroy  disoov- 
cred  a  ball  which  had  penetrated  the  foreboad,  Bnd,  travelling  along  iho 
dura  mater,  had  lodged  at  and  under  the  occipital  protuberance, 
whence  it  was  successfully  removed  by  trephining. — Sedillot  Medicine 
Uj»  ratoire.     Paris  :   1868. 


OSTITIS    OF    SKULL.  301 

present,  must  be  combated  by  rising  all  the  precau- 
tions which  have  boon  already  pointed  out 

We  might  now  sum  up,  in  a  few  words,  the  rational 
and  successful  treatment  of  gunshot  wounds  of  the 
head.  In  concussion,  unless  there  is  evident  sinking, 
leave  the  case  to  nature,  and  avoid  both  stimulation 
and  venesection.  When  the  patient  is  restored  to 
consciousness,  should  inflammation  of  the  brain  threat- 
en, if  there  be  no  congestion  of  the  face,  give  opium  to 
allay  irritation.  Should  congestion  be  evident,  use 
the  antiphlogistic  treatment,  locally  and  generally, 
with  ice  applications  to  the  head.  In  every  case  abso- 
lute quiet  and  rest  are  essential  to  successful  treat- 
ment. All  injuries  of  the  head  are  serious,  however 
trivial  they  may  seem,  inasmuch  as  violent  inflamma- 
tion often  follows  apparently  slight  wounds.  All, 
therefore,  should  be  carefully  watched  for  some  time  even 
after  the  wound  has  cicatrized. 

Chronic  ostitis,  or  periostitis,  resulting  from  gunshot 
wounds  of  the  head,  are  of  frequent  occurrence,  but 
possess  no  peculiar  interest.  Where  the  bones  have 
been  much  denuded, either  by  the  instrument  inflicting 
the  injury  or  by  subsequent  inflammation  and  suppura- 
tion, extensive  exfoliations  occur.  I  havo  seen  cases 
in  which,  as  sequclre  of  erysipelas  engrafted  upon  a 
gtinshot  wound  of  the  head,  the  frontal  or  parietal 
bone  was  gradually  isolated  and  removed.  Such  cases 
must  clearly  be  left  to  nature,  and  the  system  suit- 
ported  by  tonics  and  nutritious  food  when  debility  is 
present . 


CHAPTER    IX. 

Wounds  op  the  Faoi — Fractures  <>f  thb  Upper  and  Lowed  Jaw — 

Wounds  of  the  Netk — Large  Vessels  avoid  the  perforating 
ball — When  large  Arteries  in  the  neck  are  divided,  the  ne- 
cessity OF  LIGATING  THE  BLEEDING  .MOLTnS  IS   URGENT. 

Wounds  of  the  fack,  when  they  do  not  implicate  the 
brain,  are  not  usually  of  a  serious  character.  On  ac- 
count of  the  vascularity  of  the  tissues,  the  severe  cuts 
ahout  the  face,  made  by  the  sabre  or  by  pieces  of  shell, 
heal  very  readily  by  the  first  intention,  if  the  lips  be 
kept  in  apposition  by  sutures  or  strips  of  adhesive 
plaster.  The  application  of  cold  water  for  a  few 
days  will  usually  effect  a  cure.  The  excessive  swelling 
which  accompanies  many  injuries  of  the  face,  espe- 
cially gunshot  wounds  and  burns  from  explosion  of 
powder,  is  readily  controlled  by  cold  water  dressings. 
Although  its  appearances  are  so  frightful,  effacing  tem- 
porarily the  features,  and  exciting  much  alarm  in  the 
uninitiated,  it  runs  its  harmless  course,  moderated 
by  the  cold  applications,  and  subsides  at  the  end  of  a 
few  days.  The  rapidity  with  which  all  wounds  of  the 
face  heal  has  often  been  remarked,  and  the  large  num- 
ber of  such  wounds  make  them,  as  a  class,  familiar  to 
our  arnvy  surgeons. 

The  most  common  injuries  to  the  face  from  gunshot, 
wounds  are  fractures  of  the  upper  and  lower  jaws 
from  perforating  shot.  Round  balls  often  become  em- 
bedded in  the  soft,  spongy  bones  of  the  face,  but  minie 
balls  usually  traverse  the  face  and  escape.  When  the 
bones  of  the  face  are  struck    by  a  grapeshot  or  a  flat- 


WOUNDS    OF    PACE.  303 

tened  conical  ball  there  may  bo  great  destruction  of 
the  features,  followed  by  shocking  deformity.  But 
even  when  the  bones  are  speculated,  exfoliation  is  not 
so  general  as  in  other  portions  of  the  skeleton — a  few 
small  pieces  of  bone  escape  from  time  to  time,  but 
such  fragments  as  are  firmly  connected  with  the  soft 
parts  are  permanently  retained. 

One  or  more  of  the  senses  are  not  unfrequently 
destroyed  after  gunshot  injuries — sight  or  smell  being 
often  impaired,  if  not  completely  lost.  Where  the 
wound  involves  the  orbit,  the  loss  of  vision  is  not 
only  very  probable,  but  there  is  great  fear  that  the 
cause  producing  the  injury,  whether  it  be  a  ball,  bay- 
onet, or  a  sword  point,  may  have  perforated  the  thin 
plate  of  the  skull,  and,  entering  the  brain,  may  induce 
fatal  cerebral  inflammation.  Many  cases  of  appar- 
ently trivial  wounds  of  the  eyelids  have  terminated 
fatally,  and  an  autopsy  revealed  serious  injury  to  the 
anterior  lobes  of  the  brain  and  its  enveloping  mem- 
branes. Such  cases  should  be  carefully  watched,  and 
any  cerebral  symptoms  which  majT  arise  should  be  ac- 
tively met  by  the  antiphlogistic  treatment,  with  abso- 
lute quiet. 

From  the  great  vascularity  of  all  the  structures 
composing  the  face,  we  would  expect  to  have  serious 
hemorrhage  accompanying  all  injuries.  For  control- 
ling this  the  astringent  preparations  of  iron  may  be 
required,  although,  in  by  far  the  majority  of  cases,  the 
bleeding  ceases  spontaneously.  Should  the  carotids 
and  other  largo  arteries  have  escaped  injury,  the  iron 
styptic  will  control  the  most  annoying  hemorrhage. 
The  vessels  are  small  and  so  numerous  that  the  direct 
application  of  ligatures  can  not  be  made. 

In  fractures  of  the  upper  jaw  the  bones  are  always 
more  or  less  spiculated,  with  one  or  more  teeth  loos- 


304  TREATMENT    OF    FACE    WOUNDS. 

ened  or  completely  detached.  Sometimes  the  teeth 
are  separated  from  the  gums,  and,  driven  in  front  of 
the  ball,  are  buried  in  the  soft  parts  about  the  mouth, 
and  are  only  detected  after  the  formation  of  a  fistula. 
As  all  portions  are  frecl}T  supplied  with  blood-vesstls, 
union  will  take  place  among  the  fragments,  even  after 
considerable  shattering  of  the  bones.  Unless  the  frag- 
ments are  either  completely  detached  or  but  slightly 
adherent,  the}r  should  not  be  taken  away,  but  should 
be  replaced  with  care — as,  in  time,  consolidation  may 
take  place,  and  very  little  permanent  deformity  will 
be  left.  Should  some  of  these  fragments  die,  they 
will  be  found  loose,  often  as  early  as  the  sixth  or 
eighth  day,  and  should  be  removed.  The  cold  wa- 
ter dressings,  with  an  occasional  dose  of  salts  to  re- 
lieve the  excessive  swelling,  is  the  onty  medication  re- 
quired. The  wound  in  the  face,  after  a  careful  adjust- 
ment of  the  movable  fragments,  should  be  closed  Avith 
adhesive  plaster,  and,  with  the  use  of  coid  water 
dressings  for  a  few  days,  the  case  is  left  pretty  much 
to  nature. 

When  the  soft  parts,  as  well  as  the  bones,  are  crush- 
ed, secondary  hemorrhage  may  occur,  should  slough- 
ing tissues  come  away.  Formerly,  the  difficulty  of 
restraining  this  loss  of  blood  was  so  great  as  to 
require,  in  many  eases,  the  ligation  of  the  main  ves- 
sels in  the  neck.  We  now  find  the  local  application 
of  the  perchlorido  or  persulphate  of  iron  an  efficient 
remedy.  Should  necrosis  follow  injuries  to  the  bones 
of  the  face,  the  dead  pieces  of  bone  should  bo  removed 
as  they  become  loosened;  or  a  special  operation  may 
be  undertaken  for  ridding  the  face  of  the  local  cause 
of  trouble. 

Fractures  of  the  lower  jaw  are  not  a  rare  accident 
on  the  battle  field,  whether  caused  bj7  shot  wounds  or 


TREATMENT    OF    FACE    WOUND*?.  305 

other  casualties.  The  complicated  character  of  the 
fracture  does  not  prevent  consolidation,  which  is 
effected  in  all  cases,  although  usually  connected  with 
some  slight  deformity  from  displacement  of  the  frag- 
ments. At  times  the  entire  jaw  may  be  swept  off  by 
a  round  shot,  leaving  the  mouth  and  throat  exposed. 
One  of  the  most  fearful  cases  on  record  of  such  an  in- 
jury is  one  in  which  the  entire  face  was  carried  away  ■ 
by  a  cannon-ball,  leaving  nothing  but  the  skull  prop- 
er appended  to  the  vertebral  column.  The  opened 
gullet  marked  the  former  site  of  the  features.  The 
patient  lived  ten  houi'S,  and  from  the  frequent  change 
of  position,  and  the  squeezing  of  the  hand  when  his 
was  taken,  it  was  thought  that  consciousness  re- 
mained up  to  the  time  of  death.  Legouest  reports  a 
case  in  which  the  entire  face  was  carried  away  by  a 
cannon-ball,  the  eyes  alone  remaining  of  all  the  fea- 
tures.    This  patient  survived  the  accident. 

The  surgeon  accompanying  the  transports  usually 
sends  injuries  of  the  face  to  the  field  infirmary  un- 
touched, or,  should  the  lower  jaw  be  broken,  applies  a 
folded  handkerchief  or  band  under  it  to  support  it. 
This  fracture  is  permanently  put  up  at  the  field  infirm- 
ary in  a  pasteboard  splint,  well  padded  with  carded 
cotton,  and  secured  by  a  folded  cloth  or  double-tailed 
bandage.  One  band  passes  over  the  vertex,  support- 
ing the  jaws,  while  the  other  passes  from  the  front  of 
the  chin  behind  the  head,  and  then  around  the  fore- 
head, where  it  is  secured  by  pins.  Before  the  dress- 
ings are  applied  the  wounds  should  have  been  exam- 
ined carefully  with  the  finger,  and  all  perfectly 
detachcQ  spicule  of  bone  shoitld  have  been  removed. 
From  the  excessive  vascularity  of  all  the  tissues  of 
this  region  the  bones  do  not  necrose  as  extensively 
as  in  other  portions  of  the  body,  and  portions  of  bono 
z 


306  TREATMENT   OF    FACE    WOUNDS. 

which  are  attached  to  the  soft  parts  very  often  con- 
solidate. The  surgeon  must  be  prepared  to  meet  much 
swelling  and  profuse  salivation. 

All  gunshot  injuries  to  the  hones  of  the  face  being 
compound,  suppuration  is  soon  established,  and  the 
secretion  of  pus  is  copious.  When  (lie  hall  has  per- 
forated the  buccal  cavity,  causing  inflammation  and 
salivation,  it  will  add  much  to  the  comfort  of  the 
patient  if  his  mouth  be  swabbed  out  daily  with  a 
piece  of  soft  rag  or  sponge  attached  to  a  thin  piece  of 
wood.  From  the  difficulty  in  swallowing,  fluid  nour- 
ishment must  be  prescribed.  The  constant  thirst  of 
those  wounded  will  be  relieved  by  small  doses  of  mor- 
phine, or  by  acidulated  drinks,  made  either  with  dilut- 
ed nitric  acid  or  vinegar.  Injuries  about  the  face 
are  very  liable  to  erysipelatous  attacks,  which,  how- 
ever, are  readily  controlled  by  the  free  use  of  the 
muriated  tincture  of  iron — thirty  drops  every  three 
hours  often  checking  the  progress  of  the  disease  by 
the  end  of  the  first  day  of  treatment. 

The  most  distressing  injuries  of  the  face  are  those 
involving  vision.  When  a  minie  ball  traverses  the 
temporal  regions,  emptying  both  eyes,  there  is,  of 
course,  no  remedy.  The  case  is  equally  hopeless  whew 
injury  to  the  optic  nerve  or  optic  ganglion  occurs  in 
the  passage  of  a  ball,  although  the  globe  of  the  eye 
may  not  have  been  touched.  The  general  optbalmia 
induced  will,  by  disorganizing  all  the  tissues,  dcstroj' 
vision,  in  spite  of  treatment.  When  balls  embed 
themselves  about  the  face,  they  are  found,  often  with 
difficulty.  Time  may  develop  their  situation,  as  the 
weight  of  the  metal  may  cause  them  gradually  to  shift 
their  position  and  approach  one  of  the  open  cavities. 
When  a  ball  crushes  through  the  roof  of  the  mouth, 
throwing  the  nasal  and  buccal  cavities  into  one,  and 


WOUNDS    OF    NK.CK.  307 

affecting  both  articulation  and  deglutition,  the  serious 
annoyance  can  be  corrected  by  adapting  a  gutta-percha 
plate  to  the  roof  of*  the  mouth,  which  will  restore  the 
continuity  of  the  cavities,  and,  with  it,  other  respective 
functions.  Should  a  ball  in  its  passage  injure  the  facial 
nerve,  a  permanent  paralysis  follows  of  all  the  muscles 
of  the  face  supplied  by  it. 

Wounds  of  the  neck,  with  injury  to  the  numerous 
large  vessels  which  course  through  this  constricted  re- 
gion, are  among  the  serious  accidents  in  battle.  Prom 
the  anatomy  of  this  region  we  would  suppose  that  a 
missile  could  not  traverse  the  neck  in  any  direction 
without  destroying  some  important  part.  We  find 
among  the  wounded,  after  every  great  battle,  cases  in 
which  the  neck  has  been  perforated  by  balls  traversing 
in  every  direction.  Some  of  these  are  accompanied 
by  violent  hemorrhage,  showing  that,  from  the  course 
of  the  ball,  large  vessels  must  have  been  injured;  yet, 
should  the  patient  rally  from  the  first  fainting  brought 
on  from  shock  and  loss  of  blood,  we  find,  usually,  a 
spontaneous  cessation  of  the  bleeding,  and  the  onward 
progress  of  the  case  becomes  one  of  continued  conva- 
lescence. I  have  seen  conical  balls  perforate  the  neck 
antero-posteriorly,  entering  just  above  the  sterno-cla- 
vicular  junction,  and  passing  in  the  midst,  if  not 
through,  the  largest  vessels  of  the  body,  without  pro- 
ducing a  fatal  hemorrhage.  I  have  also  seen  them 
perforate  the  throat  laterally,  on  a  level  with  and  just 
behind  the  angle  of  the  lower  jaw,  and  a  cure  equally 
follow.  It  is  wonderful  low  the  great  vessels  escape, 
or  the  rapidity  with  which  clots  form  and  the  wounds 
of  sueli  vessels  close.  McLeod  reports  one  hundred 
ami  twenty-eight  cases,  more  or  less  severely  injured 
in  the  neek,  with  hut  four  deaths.  Many,  to  he  sure, 
die  on  the  battle-field  in  a  few  moments  after  receiving 


308  TREATMENT   OK    NECK    WOUNDS. 

a  serious  injury  to  the  large  arteries;  but,  undoubt- 
edly, many  also  recover. 

The  powerful  ii*on  styptics,  with  methodically  ap- 
plied compresses  and  bandages,  are  the  only  local 
remedies  applicable  on  the  battle-field,  as  the  assistant 
surgeon,  following  the  troops,  has  neither  the  time  nor 
conveniences  for  ligating  the  bleeding  mouths  of  the 
divided  vessel,  however  urgently  it  may  be  needed. 
A  finger  thrust  into  the  wound  and  retained  for  some 
time,  has  been  successful  in  stopping  the  bleeding  from 
apparently  large  vessels.  Should  the  field  infirmary 
be  at  no  distance  it  may  be  possible,  by  pressure  in 
the  wound,  to  control  the  bleeding  until  the  soldier 
can  bo  conveyed  to  this  point  of  safety,  when,  if  the 
hemorrhage  continue,  an  operation  may  be  performed; 
but  so  seldom  is  thi*  at  a  convenient  distance,  that  if 
the  bleeding  does  not  soon  cease  spontaneously  or  be 
rapidly  checked  by  the  stypties  used,  the  patient  dies 
— no  case  of  ligation  of  the  large  vessels  of  the  neck 
having  been  yet  reported  from  our  battle-fields. 

The  precautions  which  were  urged  in  discussing  the 
means  of  arresting  hemorrhage  in  wounds  generally, 
must  here  be  carefully  applied;  and  should  secondary 
hemorrhage  occur,  notwithstanding  the  careful  appli- 
cation of  the  iron  styptic,  the  safety  of  the  patient  will 
then  lie  only  in  the  ligation  of  both  bleeding  orifices.  The 
anastomosis  of  the  blood-vessels  in  the  neck  are  so  free, 
and  the  vessels  so  numerous,  that  there  would  be  much 
difficult}' in  diagnosis;  and  as  the  rule  is  to  determine, 
if  possible,  the  precise  seat  of  hemorrhage,  it  can  only 
be  verified  by  the  dilatation  of  the  wound.  A  ligature 
upon  the  carotid  artery,  at  a  short  distance  both  above 
and  below  the  wound,  has  been  reported  a  failure  in 
controlling  a  hemorrhage,  which  was  only  checked  by 
dilating  the  wound  and  ligating  the  artery  at  the  point 


TREATMENT    OF    NKCK    WOUNDS.  309 

injured.  And  at  page  206  will  be  found  the  report  of  a 
case  in  which  both  common  carotids  were  ligated  for 
the  injury  of  a  comparatively  small  branch — the  hyoid 
artery.  The  patient  died.  Had  the  rule  of  dilating 
the  wound  and  of  ligating  both  orifices  of  the  bleeding- 
vessel  been  followed,  which  is  more  imperative  in  neck 
injuries  than  in  those  of  any  other  portion  of  the 
body,  the  patient  would,  most  probably,  have  been 
saved.  Should  the  large  veins,  when  injured,  persist 
in  bleeding,  they  should  be  also  ligated.  In  enlarging 
the  wound,  the  incision  will  always  be  made  parallel 
with  the  axis  of  the  neck,  so  as  to  avoid  injuring  im- 
portant nerves  or  blood-vessels. 

Several  instances  have  occurred  in  the  Confederate 
campaigns  where  the  trachea  has  been  perforated  by  a 
shot  or  the  larynx  carried  awa}'.  Such  contraction 
of  the  air  passage  and  difficulty  of  breathing  follows 
upon  this  accident,  as  to  force  the  patient  to  wear, 
permanently,  a  trachial  tube,  to  protect  him  from 
attacks  threatening  suffocation.  In  such  cases  the 
voice  is  reduced  to  a  whisper. 


OHAPTBB    X. 

Wounds   of  the   Cbbst — Fi  iss   Wounds — Bffi  bionb    within  the 
CAVITY  WHEN  the  Plei  ra  is  injured — Wounds  of  the  Heart  or 

Lis*.       A   TBAH8FIXED  ClIEST  DOES    NOT    N  E(  'ESSARILY   IMPLY    A    Pk.R- 

forated  Lung  — Diagnostic  value  of  the  various  Symptoms — 
Ho  Moi'TYsis,  Dyspnosa,  Collapse,  Emphysema — Treatment  or 
Chest  Wouhos — How  inflammatory  complications  are  to  be 
combated — the  treatment  of  a  fractured  rlb — contusions  and 
injuries  of  the  Spine. 

Wounds  of  thk  chest,  when  taken  as  a  class,  arc, 
perhaps,  the  most  fatal  of -gunshot  wounds.  Many  are 
shot  down  and  die,  more  or  less  rapidly,  on  the  battle- 
field from  internal  hemorrhage,  with  its  accompanying 
suffocation,  and  are  returned  among  the  killed.  Era- 
ser, in  an  excellent  treatise  on  chest  wounds,  based 
upon  data  obtained  in  the  Crimea,  states  the  mortality 
to  have  been  twenty-eight  per  cent,  of  all  chest  wounds, 
and  seventy-nine  per  cent,  of  those  in  which  the  lung 
had  been  injured.  The  Russian  Crimean  reports  give! 
as  their  mortality  in  chesl  wounds  ninety-eight  per 
cent.,  which  is  sufficient  proof  of  the  serious  character 
of  this  lesion.  The  danger  in  wounds  of  the  thorax  is 
from  visceral  complications.  Should  the  lung  be  se- 
verely injured,  the  ease  usually  terminates  fatally. 

From  the  peculiar  formation  of  the  thoracic  box 
and  the  curve  of  the  ribs,  halls,  in  striking,  are  often 
deflected  from  the  straight  line,  and,  alter  a  longer  or 
shorter  course,  escape  without  having  penetrated  tho 
chest.  Often  the  two  openings  correspond  so  accu- 
rately in  direction  as  to  establish  a  strong  conviction 
of  a    direct    passage    through   or  across    the  thorax, 


WOUNDS    OF    C1IKST.  oil 

when  the  wound  has  been  but  a  subcutaneous  one 
throughout.  I  have  seen  an  instance  in  which  a 
ball,  which  had  entered  the  chest  just  below  the  left 
armpit,  was  removed  from  a  similar  position  in  the 
right  side  as  if  it  had  traversed  the  thorax;  its  entire 
course  having  been  subcutaneous,  no  inconvenience 
was  experienced.  This  tortuous  track  can  only  be 
made  by  a  ball  striking  at  a  considerable  obliquity. 
Its  direction  is  generally  indicated  by  a  reddish  or 
purplish  line  under  the  skin,  which,  when  followed  by 
the  finger  pressed  on  the  surface,  imparts  a  crackling 
sensation,  caused  by  air  in  the  cellular  tissue.  Such 
injuries  are  usually  simple,  and  require  but  little  treat- 
ment. The  eold  water  dressing  fills  every  indication, 
and  its  applieation  for  a  few  days  usuall3T  effects  a 
cure. 

A  great  amount  of  nervous  shock  often  accompanies 
very  trivial  injuries  of  the  chest.  Many  instances  aro 
mentioned  by  military  surgeons  in  which  balls  had 
struck-  articles  about  the  person  of  the  soldier — the 
breast-plate  of  a  cuirassier,  or,  perhaps,  a  book  in  the 
breast-pocket  of  a  soldier's  coat — and  had  fallen  to  the 
ground  without  even  touching  the  skin,  yet  the  sol- 
dier had  been  knocked  down  breathless,  and.  in  some 
eases,  did  not  recover  completely  from  the  shock  for 
days.  In  some  of  the  cases  the  lungs  are  so  much 
concussed  by  the  blow  that  blood  escapes  from  the 
mouth  as  in  perforating  wounds. 

Where  a  ball  traverses  the  out*  r  side  of  the  chesl 
antcro-posteriorly,  although  the  cavity  may  not  have 
been  opened,  there  may  be  the  very  serious  complica- 
tion of  injury  to  the  axillary  artery  as  it  courses  un- 
der the  ({reat  pectoral  muscle.  Pressure  with  the 
thumb  upon  the  subclavian  vessel  above  the  middle 
of  the  clavicle  as  it  passes  over  the  first  rib,  will   con- 


'61-  PERFORATING    WOUNDS   01   Cfll 

trol  the  bleeding  sufficiently  to  allow  the  wound  to  bo 
dilated,  when  both  bleeding  orifices  should  be  secured. 

Should  the  ball  have  penetrated  the  chest,  it  may 
course  for  some  distance  between  the  ribs  and  their 
lining  membrane,  when  it  may  either  escape  from  the 
cavity  and  be  found  under  the  skin,  or  remain  capped  , 
by  the  pleura.  Such  cases  may  give  no  trouble,  or 
pleuritis  may  ensue,  which  the  rational  signs,  with 
ausculation,  will  detect,  and  an  antiphlogistic  course, 
accompanied  with  the  free  use  of  opium,  will  readily 
subdue.  Opium,  when  used  in  large  and  frequently 
repeated  doses,  possesses  other  virtues  than  merely 
allaying  pain  and  quieting  nervous  symptoms.  It 
combats,  directly,  inflammation,  and,  by  the  great 
control  which  it  exercises  over  the  brain  and  circula- 
tion, becomes,  in  the  treatment  of  the  serious  sequehe 
of  wounds,  one  of  the  most,  if  not  the  most,  valuable 
remedy  of  the  materia  medica.  When  given  in  com- 
bination with  nitrate  or  carbonate  of  soda,  its  nau- 
seating effects  are  counteracted. 

The  evil  which  the  surgeon  fears  from  perforating 
wounds,  followed  by  inflammation,  is  that  a  serous  or 
sero-purulent  effusion  may  rapidly  accumulate  in  the 
thoracic  cavity,  and  destroy  the  patient.  So  rapidly 
is  this  fluid  formed,  that  the  chest  has  been  known  to 
fill  in  twenty-four  or  forty-eight  hours — the  fluid  com- 
pressing and  condensing  the  lung  against  the  verte- 
bral column.  In  expanding  the  chest,  it  will  be 
found  that  as  soon  as  a  thin  layer  of  fluid  is  effused 
into  the  cavity,  separating  the  lung  from  the  thoracic 
wall,  the  respiratory  murmur  becomes  very  feeble, 
and  will  altogether  disappear  when  the  cavity  is  filled. 
At  the  same  time  respiration  becomes  much  embar- 
rassed, with  marked  dyspnoea.  Percussing  the  side 
will  now  give  a  dull,  heavy  sound,  instead  of  the  ordi- 


PERFORATING    WOUNDS    OF    CTIE6T.  313 

nary  clear,  sonorous  one  of  health  ;  and  the  position 
of  the  patient  must  vary  the  sound  by  the  gravitation 
of  the  serous  collection  unless  the  cavity  is  filled  with 
fluid.  The  lung  is  condensed  and  flattened  against 
the  vertebral  column,  and  is  temporarily  impervious 
to  air;  under  a  long  continuance  of  the  pressure,  it 
will  become  permanently  consolidated.  The  increase 
in  the  circumference  of  the  chest,  and  the  fulness  of 
the  intercostal  spaces,  with  the  absence,  to  a  great  ex- 
tent, of  respiratory  movements  upon  the  affected  side, 
the  displacement  of  the  heart  from  its  usual  posi- 
tion— being  found  on  the  right  side,  whei*c  the  effu- 
sion fills  the  left  pleural  cavity,  and  vice  versa — and 
great  oppression  of  the  breathing,  with  inability  to 
lie  upon  the  healthy  side,  are  conspicuous  symptoms 
of  a  distended  cavity. 

The  quantity  of  fluid  thrown  out  varies  from  a  few 
ounces  to  several  pints.  When  the  natural  dimen- 
sions of  the  cavity  are  not  sufficiently  extensive  to 
accommodate  it,  it  forces  the  mediastinum  over  to 
the  sound  side,  interfering  with  the  action  of  the 
healthy  lung,  while  an  encroachment  may  be  equally 
made  upon  the  abdomen. 

When,  after  gunshot  wounds,  accompanied  by  dis- 
tressing symptoms  of  dyspnoea,  the  surgeon  recog- 
nizes such  collections  as  rapidly  forming  in  the  chest, 
an  earl}7  evacuation  will  be  required.  Should  the  col- 
lection be  purulent  and  show  a  disposition  to  point, 
an  opening  for  the  escape  of  the  fluid  should  be  made 
at  the  point  which  nature  indicates;  but,  in  cases  of 
excessive  effusion,  the  broad  intercostal  space,  be- 
tween the  sixth  and  eighth  ribs  on  the  right,  or  be- 
tween  the  seventh  and  ninth  on  the  left,  might  be 
the  point  selected.  The  instrument,  usually  a  trocar 
and  canula,  should  bo  introduced  at  right  angles  to 
Aa 


81  I  WOUNDS   OF    HEART. 

Ihe  chest  and  near  the  upper  edge  of  the  rib,  toward 
its  angle,  in  a  line  continuous  with  the  posterior  bor- 
der  of  the  armpit.  As  this  puncture  corresponds 
with  the  lowesl  portion  of  the  cavity,  the  chesl  ran 
be  perfectly  drained  through  it. 

In  all  gunshot,  injuries  of  the  chest,  the  most  serious 
complication  is  injury  to  the  lungs  or  heart,  and  it  is 
often  difficult  to  detect  at  first  Buch  lesions.  Notwith- 
standing the  many  infallible  signs  laid  down  by  an 
thors,  experience  teaches  us  that  Yio  one  symptom  is 
sufficient  for  establishing  a  diagnosis.  When  the  heart 
is  injured,  although  instantaneous  death  does  not  take 
place  as  a  general  rule,  the  wounded  man  lives  but  a 
short  period.  The  pericardium  soon  becomes  tilled 
with  blood j  the  action  of  the  heart   is  mechanically 

impeded,  and,  sooner  or  later,  depending  upon  the 
size  of  the  wound  and  i  he  facility  for  letting  out  blood, 
it  erases  its  pulsation.  As  reports  of  cases  arc  not 
very  rare  in  which  small,  oblique,  incised  wounds  of 
the  heart  have  been  recovered  from — and  even  gun- 
shot wounds  of  this  organ,  perforating  its  cavities, 
have  escaped  with  life — a  wound  of  the  heart  is  not 
considered  necessarily  a  fatal  accident.  When  the 
pericardium  is  perforated  and  the  heart  not  injured,  a 
successful  result  may  readily  he  obtained  by  a  judicious 
course  of  treatment,  which  will  keep  down  inflamma- 
tion, with  its  effusions  of  lymph  and  serum.  Close 
carefully  the  outer  wound,  so  as  to  induce  healing  by 
the  first  intention,  but  otherwise  Leave  the  case  to 
the  vis  medicatrix  natura,  avoiding  all  excitants,  keep- 
ing the  patient  quiet,  and  instituting  a  non-stimulating 
diet. 

The  lung  often  escapes  injury  when,  from  the  po- 
sition of  the  wounds  of  entrance  and  of  exit,  with  the 
certainty  of  the  cavity  being  transfixed,  the  natural 


luno  wouNns.  315 

belief  would  lead  to  a  perforation  of  the  organ.  A 
straight  line  between  the  wounds  passes  evidently 
through  the  substance  of  the  lung,  but  the  ball,  in  per- 
forating the  rib,  may  have  been  deflected  from  its 
straight  course,  and  following,  perhaps,  the  inner  curve 
of  the  chest,  and  meeting  with  some  resistance,  had" 
forced  its  way  through  the  chest — either  appearing 
under  the  tough,  elastic  skin,  or  cutting  its  way  out 
Without  having  touched  the  contained  organs. 

The  lung  may,  on  the  other  hand,  be  severely  injured 
when  no  perforating  wound  exists.  A  blow  by  a  spent 
ball  or  a  fragment  of  shell  may  make  a  very  superfi- 
cial wound  or  bruise  in  the  skin,  and  yet  may  shatter 
one  or  more  ribs,  driving  the  spicule  into  tho  lung, 
lacerating,  to  a  greater  or  less  extent,  its  substance. 
Even  without  fracture  of  the  ribs,  the  concussion  or 
blow  may  have  been  sufficiently  great  to  have  caused 
irreparable  injury. 

The  following  cases,  extracted  from  a  Memoir  on 
Amputations,  by  Baron  Larrey,  will  exhibit  the  extent 
of  internal  injury  from  a  spent  ball  without  external 
indications  of  mischief: 

"At  the  Siege  of  Roses  there  were  brought  from  tho 
trenches  to  the  ambulance  that  1  had  established  at 
the  Village  of  Palace,  two  gunners,  having  nearly  the 
same  kind  of  wound j  they  had  been  struck  by  a  ball 
of  large  calibre,  which,  when  nearly  spent,  had  grazed 
posteriorly  their  two  shoulders.  In  the  first  I  dis- 
covered a  slight  ecchj'mosis  over  tho  whole  posterior 
part  of  the  trunk,  without  anj-  apparent  solution  of 
continuity,  lie  was  hardly  able  to  breathe,  and  sjiit 
up  :i  great  quantity  of  vermilion  and  frothy  blood, 
The  pulse  was  small  and  intermitting,  and  the  extremi- 
ties cold  ;  in  short,  lie  died  an  hoar  after  the  accident, 
:t-  1  had  prognosticated      \  opened  the  body  in  the 


316  HEMORRHAGE    IN    0HES1    WOUNDS 

presence  of  M.  Dubois,  inspector  of  military  bospitala 

The  skin  was  unhurt;  the  muscles,  the  aponeuroe 
the  nervea  and  vessels  of  the  'shoulder,  were  broken 

and  torn,  the  scapula-  fractured,  the  spinous  proccs 
of  the  corresponding   vertebrae  of  the  hack  and  the 

posterior  extremities  of  the  neighboring  ribs  Tract  ored  ; 
the  Bpinal  marrow  was  distended,  the  parenchyma  of 
the  lungs  toward  the  corresponding  points  were  lacer- 
ated, and  a  considerable  effusion  had  taken  place  into 
both  cavities  of  the  thorax.  The  second  gunner  died. 
with  the  same  symptoms,  three-quarters  of  an  hour 
after  his  entrance  into  the  hospital.  On  opening  the 
body  the  same  mischief  was  perceived  as  in  the  first." 

The  severity  of  the  Bymptoms  will  depend  upon  the 
portion  of  the  lung  injured,  and  also  the  depth  of  the 
wound  in  the  lung.  Where  a  hall  traverses  the  peri- 
pheral substance  of  the  lung,  whether  it  be  at  the  apex 
or  base,  where  the  vessels  are  broken  up  into  their 
minute  ramifications,  the  case  is  usually  less  serious, 
and  much  more  likely  to  recover,  than  when  the  root 
of  the  lung  is  perforated.  The  injury  in  this  case 
would  implicate  the  large  vessels  passing  to  and  from 
the  heart,  and  hemorrhage  may  be  so  rapid  and  ex- 
cessive as  to  be  immediately  fatal.  It  is  on  account  «>t' 
the  loss  of  blood  that  the  most  conspicuous  symptoms 
arise,  viz:  hemorrhage,  collapse,  cough,  and  dyspnoea, 
or  oppressive  breathing. 

The  patient  may  be  at  once  suffocated  by  a  large 
quantity  of  blood  filling  up  the  thorax  and  pre- 
venting the  ingress  of  air  into  the  lungs.  Usually 
blood  passes  from  both  the  mouth  and  the  wound. 
When  the  smaller  vessels  are  injured,  thai  from  the 
mouth  is  froth}-  and  florid,  and  is  brought  up  by  a 
short,  tickling,  harassing  cough.  Where  the  vessels 
injured  are  of  larger  sizo,  the  blood  comes  up  from  tho 


HEMORRHAGE  IN  CHEST  WOUNDS.        317 

chest  in  a  purer  condition  and  in  larger  quantity,  at 
times  in  nearly  a  stream,  filling  the  mouth  as  rapidly 
as  it  could  be  spit  out,  and  threatening  suffocation. 
The  size  of  the  dark-colored  stream  pouring  from  the 
wound  depends  upon  the  position  of  the  orifice. 
Where  the  orifice  is  situated  low  upon  the  chest,  and  is 
large  and  direct,  the  effusion  into  the  cavity  escapes 
freely — the  symptoms  of  collapse  may  soon  appear, 
but  suffocation  is  prevented;  while  from  an  injury 
in  the  upper  portion  of  the  chest,  particularly  if  small 
and  oblique,  the  thorax  may  fiLl  with  blood,  and  suffo- 
cation becomes  imminent,  without  much  external  loss. 
The  danger  from  hemorrhage  is  greatest  during  the 
first  twelve  hours,  and  is  pretty  well  over  by  the  sec- 
ond day.  The  bleeding  may,  however,  continue  for 
eight  or  ten  days.  graduall}T  diminishing  in  quantity. 
With  the  flow  of  blood  from  the  wound  air  often 
escapes,  and  the  two  symptoms  are  considered  unequiv- 
ocal proof  that  the  lungs  have  been  injured — their  ab- 
sence does  not  prove  the  contrary.  We  meet  with 
cases  of  perforation  of  the  lung  terminating  fatally  at 
the  end  of  thirty-six  or  forty-eight  hours,  in  which 
collapse  had  been  the  only  conspicuous  sympfom — 
no  hemorrhage  may  have  been  present  either  from 
mouth  or  wound — }-et  an  autopsy  will  reveal  the 
chest  filled  with  blood. 

The  mere  loss  of  blood  from  the  lung  is  no  certain 
indication  that  the  organ  has  been  injured,  as  bloody 
expectoration  is  a  common  symptom  of  blows  upon  the 
chest,  and  arises  from  a  sudden  concussion  of  tho  or- 
gan. Eraser,  in  his  recent  work  on  gunshot  wounds 
of  the  chest,  places  less  value  on  hemoptysis  than  do 
Other  military  Burgeons.  Guthrie  considers  it  a  proof 
of  lung  wound;  so  do  Baudens,  licLeod,  Stromyer, 
Ballingall,  and  others.     Eraser's  experience  in  the  Cri- 


319  DYSPNOSA    IN    0HE8T    W01  N 

gives,  in  nine  t':it:il  cases  in  which  the  lungs  were 
wounded,  but  one  instance  of  haemoptysis,  and  in 
seven  fatal  cases  in  which  the  lungs  were  not  injured, 
two  had  spitting  of  blood.  In  twelve  cases  of  n 
ery,  three  had  hemoptysis,  Prom  our  large  experi- 
ence of  perforating  chest  wounds  we  would  infer  that 
the  Bpitting  of  blood  is  :i  very  deceptive  diagnostic 
Btgn  of  lung  wound.  When  it  is  rapidly  brought  up 
by  moutlifuls,  it  hecomes  an  important  symptom. 

The  discharge  of  blood  from  the  wound  is  Borne- 
times  occasioned  by  injury  to  the  intercostal  vessel; 
hut  this  is  so  rarely  the  case  thai  McLeod  states  that 
he  neither  saw  nor  heard  of  an  instance  during  the 
Crimean  war. 

The  most  distressing  symptom  is  dyspnoea,  which 
uia\  appear  soon  after  the  injury  has  been  received, 
or  perhaps  not  until  some  days  have  intervened;  in 
certain  cases  of  undoubted  lung  injury  it  may  not 
been  present  at  any  time.  This  symptom  is  some- 
times \<ry  intense — from  moral  or  other  causee 
when  the  lung  is  not  wounded,  and  it  may  be  bull 
slightly  marked,  or  even  altogether  absent,  when  the 
lung  is  seriously  implicated.  This  difficulty  in  breath- 
ing depends,  in  some  instances,  upon  the  direct  press- 
ure and  condensation  of  the  lung  by  air  or  by  fluids. 
When  the  chest  has  been  opened  by  a  ball  the  lung 
does  not  oollapse,  as  is  generally  supposed,  but,  if  the 
opening  is  sufficiently  large,  can  be  seen  moving  to 
and  fro  against  the  thoracic  walls  simultaneously 
with  respiration  ;  and.  as  a  proof  of  the  continued  ac- 
tion of  the  lung,  and  its  inflation  with  air,  it  is  BO  me- 
times  found  protruding  from  the  orifice,  forming  a 
hernia  of  the  organ.  Even  when  the  lung  has  been 
Completely  perforated,  it  does  not  necessarily  collapse  ; 
hut  as  blood  escapes  into  the  pleural  cavity,  the  lung 


DTSPNOSA    IN    CHEST   WOUNDS.  319 

maybe  gradually  pushed  back  and  condensed  against 
the  vertebral  column,  with  all  the  accompanying  symp- 
toms of  dyspnoea.  From  injury  to  the  lung  and  con- 
tinued pumping  of  air  into  the  pleural  sac,  when  an 
opening  exists  in  the  chest  for  its  ready  escape,  we 
sometimes  find  similar  difficulties  in  respiration  in- 
duced. 

Emphysema  is  a  symptom  Of  injury  to  the  lung  upon 
which  much  importance  has  been  placed,  and  yet  is  a 
sign  which  our  extrusive  experience  shows  to  be  rare- 
ly present.  It  ma}'  be  occasioned  by  any  circum- 
stance which  admits  air  into  the  pleural  cavity,  where, 
being  compressed  by  the  action  of  the  lung  and  walls 
of  the  chest,  it  is  forced  out  through  the  wound.  Should 
a  ready  exit  not  be  offered  for  its  escape,  or  should  any 
Obstacle  exist  in  the  form,  size,  or  direction  of  the 
wound,  the  air  would  be  forced  into  the  cellular  tissue. 
Owing  to  the  free  communication  in  the  interstices  of 
areolar  tissues,  it  diffuses  itself  widely  and  rapidly. 
Should  a  perforated  wound  from  a  ball  or  other  weap- 
on allow  air  to  enter  the  pleural  cavity,  whether  the 
lung  be  injured  or  not,  emphysema  might  appear.  It 
is  not  bo  frequently  met  with  after  gunshot  wounds, 
because  the  large  orifice  of  entrance  offers  a  free 
exit  to  the  contents  of  the  cavity.  It  is  a  much 
more  common  accompaniment  of  oblique  punctured 
wounds,  and  is  also  met  with  in  cases  of  fractured 
vilis.  when  sharp  spieulao  of  bone  have  abraded  the 
Surface  of  the  lung  and  allowed  air  to  escape  from 
the  air  tubes  into  the  cavity.  As  it  is  found  either 
with  or  without  lung  injury,  it  can  not  be  of  much 
value    in    diagnosis.      The    injured    lung,    in    gunshot 

wounds,  do.s  not  often  permit  air  to  escape  for  any 

,i  of  time  from  its  wounded  surface,  ;^  an  imme- 


320  COLLAPSE    IN    OHEST    WOUNDS. 

diate  extravasation  of  bloo  i  into  the  braised  tissae 
closes  up  the  small  air  tabes,  and  shuts  off  oommu> 
nication  with  the  cavity. 

Another  Bymptom  of  great  value  is  collapse,  depend* 
ing  upon  loss  of  blood.  It  is  well  known  thai  all  the 
blood  of  the  body  must  continually  pass  through  the 
lungs j  and  Bhould  the  vessels  composing  tin-  Daren* 
ehyma  «»t'  this  organ  be  extensively  opened,  the  loss 
in  even  a  short  period  must  be  excessive.  It  is  not 
surprising,  therefore,  that  the  patient  should  soon  !"■- 
come  cold,  pale,  and  faint — with  feehle,  small,  and  ir- 
regular pulse,  ami  with  rapid  tendency  to  syncope. 
This  is  nature's  efforl  to  chock  further  1>>ss;  ami  al- 
though sometimes  successful,  often  gives  hut  tempora- 
ry security.     The  surgeon  tries  to  induce  this  condu 

tion  for  a  similar  purpose. 

Prom  the  consideration  of  the  above  symptoms,  we 
are  induced  t<>  believe  that  no  one  symptom  is  pathog- 
nomonic of  injury  to  the  lung;  it  is  rather  from  a 
combination  of  phenomena  that  any  certainty  in 
diagnosis  is  attained.  The  immediate  danger  and  in- 
tensity of  the  symptoms  will  depend  upon  the  depth  <>f 
the  penetration.     Wherethe  chest  is  only  superficially 

WOUIlded,  although  the  force  of  the  Mow  may  he  Buffi- 
Oienl  to  pro. line  an  amount  of  shock  of  shorter  .  r 
longer  duration,  and  blood  may  he  expectorated  from 
the    COnCUSSiOC    of    the    lungs,    the    symptom-,    will     he 

trivial.    The  pain  of  the  bruised  tissues  will  pass  off  in 

a  few  days,  ami  with  it  all  the  accompanying  svmp- 
toms.  When  the  chest  has  heen  Opened  without  inju- 
ry to  the  long,  heart,  or  intercostal  vessels,  the 
symptoms  are  also  trivia] ;  and  unless  inflammation  of 
the  pleura,  and  subsequenl  effusions  of  serum  or  pus 
should  ynsue,  the  case   will  equally  require  hut  little 


sYMl'ToMs   OF    LUNG    WOUNDS.  821 

treatment.  When  the  hi  1 1  <^  is  implicated,  and  especially 
when  severely  wounded,  other  symptoms  are  more  or 
less  conspicuously  present. 

Soon  after  the  reception  of  a  severe  wound  blood 
pours  from  the  injured  vessels,  and  escapes  both  into 
the  air  tubes  and  into  the  pleural  cavity.  From  the 
air  vessels  it  is  brought  up  and  expectorated,  in  greater 
or  less  quantify,  as  in  haemoptysis,  while,  at  the  same 
time,  it  flows  from  the  external  wound  in  the  side. 
If  the  openings  in  both  lung  and  chest  be  free,  the 
blood  escaping,  both  by  the  wound  and  the  mouth, 
is  mingled  with  air  when  the  patient  coughs.  The 
air  is  forced  from  the  chest  wound  in  such  a  blast 
as  to  extinguish  a  lighted  candle.  With  the  loss  of 
blood,  the  surface  becomes  cold  and  bedewed  with  a 
cold  perspiration;  the  pulse  is  weak  and  tremulous, 
becoming  more  and  more  enfeebled  until  syncope 
comes  on,  which  temporarily  checks  the  excessive 
bleeding.  Should  the  orifice  in  the  side  offer  an  im- 
perfect escape  to  the  blood,  and  the  vessels  injured  be 
large,  it  collects  in  the  pleural  cavity,  rapidly  en- 
croaches upon  the  lung,  which  is  forced  back  against 
the  spinal  column,  and,  by  compressing  the  opposite 
side  of  the  chest  through  the  mediastinum,  threatens 
suffocation.  The  eyes  protrude,  nostrils  expand  to 
their  utmost,  the  arms  are  thrown  about  in  every  di- 
rection, and  frightful  struggles  for  breath  appear  in 
every  feature.  These  are  the  cases  which,  if  not  re- 
lieved by  the  free  escape  of  blood  externally,  will,  in  a 
few  moments,  terminate  fatally  b}r  suffocation.  Where 
the  bleeding  occurs  from  small  vessels  the  pressure  is 
so  gradually  increased  that  the  above  symptoms  are 
not  observed. 

The  simple  cases  of  chest  wound,  requiring  no  imme- 
diate attendance,  will  be  sent  on  to  th«-  field  infirmary, 


TRKATMK.NT     IN    CHE8T     WOl   N 

and  although  the  woand  lias  evidently  transfixed  the 
chest,  if  no  argent  Bymptoms  exist,  the  case  requires 
no  treatment  from  the  ambulance  surgeon.  The  sur- 
geon at  the  field  infirmary  removes  any  rough  field 
dressing,  and.  where  foreign  bodiea  arc  suspected, 
examines  the  wound  wiih  the  finger.  It  the  orifice  be 
aol  sufficiently  large  to  permit  a  thorough  search,  he 
dilates  it  with  a  probe-pointed  bistoury. 

In  perforating  chest  wounds,  unless  urgent  symp- 
toms of  dyspnoea  are  present,  the  general  treatment  is 
purely  of  the  expeotant  plan.  The  wound  having 
been  carefully  closed  with  a  strip  of  diachylon  plaster, 

the    patient    lies  on    the  wounded    Bide,  80   as    to  throw 

the  lung  against  the  orifice,  hoping  that  it  may  adhere 
to  the  chest  at  that  point,  and  so  close  permanently 
the  cavityj   he  also  finds  this  the  most  comfortable 

position.      He  i^  kept  quiet  ;   all  excitants  are  avoided; 

abstemious  diet  is  instituted;  vcratrum  viride  or  digi- 
talis may  lie  given  to  control  the  action  of  the  heart  ; 
opium  is  freely  administered  to  quiet  the  constant 
backing,  tickling  cough,  and  cold  water  dressings  are 

applied  to  the  chest.  With  >iieh  treatment  and  Care- 
ful watching,  Beeing  the  patient,  if  possible,  every  one 

or  two  hours,  we  await  the  development  of  symp- 
t s.      The    accurate    cl08Ure   of   the    wound   excludes 

the  admission  of  air,  to  a  certain  extent  prevents 
emphysema,  and  also  the  rapid  decomposition  of  the 
escaped,  fluids  in  the  cavity,  which  indirectly  prevents 
inflammation. 

[f    it    be   a   shot    wound,    with    a    single   orifice,    and 

portions  of  the  clothing  he  foond  wanting,  the  wound 

should    he    examined    for    foreign    hodies.       If   found, 

extiaet  them;  if  not  detected,  then  close  the  wound 
carefully    with  a  strip  of  diachylon,  and  apply   the 

water  01'  ICO  dressing. 


TREATMENT    IN    CHEST    WOUNDS.  I!'-.'! 

The  search  for  foreign  bodies  must  always  be  made 
with  the  finger,  and  should  never  he  protracted. 
Should  nothing  be  found  after  a  moderate,  intelligent 
Bearch,  close  the  wound  and  await  developments. 
This  examination  should  be  made  before  reaction 
(•nines  on.  Should  we  not  see  the  patient  until  he  is 
Feverish,  all  examinations  must  be  absolutely  forbid- 
den until  reaction  has  subsided  and  suppuration  be 
well  established. 

it  is  well  known  that  balls,  etc., — even  pieces  of 
clothing— have  often  been  found  encysted  in  the  lungs 
years  after  they  had  been  deposited;  and  in  some  in- 
stances these  articles  have  been  expectorated,  during 
a  severe  spell  of  coughing,  after  a  long  interval  from 
the  receipt  of  the  injury.  Although  always  desir- 
able to  remove  these,  a  prolonged  search  may  entail 
such  an  amount  of  injury  as  to  destroy  all  hope 
of  saving  the  patient,  when  the  presence  of  the  for- 
eign body  would  not  have  been  necessarily  incom- 
patible with  life,  or  even  health.  Besides,  when  sup- 
puration is  well  established,  we  have  a  second  and 
much  better  opportunity  for  a  careful  examination, 
without  much  fear  of  doing  injury. 

A  case  in  point  was  reported  to  the  association  of 
array  surgeons al  their  meeting  in  February,  l^:i}.  by 
Surgeon  Tliom.  as  communicated  to  him  by  Surgeons 
Seldcn  and  Moore : 

"The  patient,  of  scrofulous  habits,  t  wenty-two  years 
of  age,  was  leaning  on  his  gun,  the  muzzle  in  contact 
with  his  left  side,  when  it  exploded,  tearing  a  hole  in 
the  chot  of  three  Or  four  inches  in  diameter,  carrying 

with  the  load  of  shot  fragments  of  tic  third,  fourth, 

and  fifth  l-il's,  ami  the  whole  of  a  very  heavy  English 
gold  patent-lcvei-  watch,  exoepl  the  ring  to  which  the 
chain  was  attached — which,  singular  to  say,  was  found 


:524  TKKATMKNT    in    0HE8T   WOt  nds. 

in  the  Lining  of  his  waistcoat,  on  tbe  right  side.     Dr. 

.Seidell   found  the   patient  apparently  about   t<»  expire, 

and.  from  the  impending  suffocation  upon  the  ingress 
of  air  within  bo  Large  an  opening,  he  could  make  do 

exploration   of  the   wound.      Closing  the  wound   with 

a  large  compress  and  bandage,  opium  and  stimulants 
were  freely  administered.  Reaction  took  place,  and 
in  a  fortnight  sufficient  adhesions  were  established  to 
permit  exposure  of  the  cavity  of  the  wound,  and  to 
recognize  and  to  remove  the  metal  face  of  the  watch, 
from  some  six  inches  at  the  bottom  of  the  wound. 
For  several  weeks  fragments  of  the  watch  continued 

to  present  themselves  and  were  extracted — sonic  from 

the  diaphragm,  others  below  the  clavicle.     The  lung 

Collapsing  was  not  torn  to  pieces,  though  wounded  iii 
several  points.  Both  the  heart  covered  hy  the  peri- 
cardium and  the  aorta  were  exposed  to  view  and  to 
touch.  Suppuration  was  enormous — hemorrhages  fre- 
quent. The  collapsed  lung  became  hound  down  by 
adhesions;  the  whole  side  of  the  thorax  sunk.  Sus- 
tained by  every  article  of  nutritious  food  calculated  to 
supply  an  inordinate  appetite,  the  patient's  recovery 
was  slow  until  the  wound,  progressively  reduoed, 
could  only  admit  a  female  catheter.  Fragments  of 
the  watch  and  hone,  together  with  shot  and  other 
extraneous  matters,  continued  for  some  time  to  he 
ejected  by  expect  orat  ion,  with  sputa.  The  patient 
now  possesses  every  part  of  the  watch  except  the 
hands,  a  considerable  portion  of  the  small  works  hav- 
ing been  expectorated.  The  openings  into  the  lung 
were  of  sufficient  Bise  to  allow  a  current  of  air  to  es* 
cape,  and,  if  directed  against  the  flame  of  a  candle,  to 
extinguish  it.  The  patient's  health  continues  feeble, 
but  is  as  robust  as  it  had  been  during  the  past  live 
year-  " 


TREATMENT    IN    CHEST    WOUNDS.  325- 

When  active  hemorrhage  occurs  within  the  cavity, 
two  diametrically  opposite  courses  are  recommended 
by  military  surgeons  of  experience.  Many  advise 
that  the  wound  should  be  kept  open,  so  as  to  allow 
the  free  ingress  of  cold  air  into  the  cavity,  which,  as  a 
haemostatic  of  great  value,  may  be  influential  in  con- 
stringing  the  injured  blood-vessels  and  stopping  the 
hemorrhage.  Other  surgeons  recommend  that,  in 
such  cases,  the  orifice  be  closed  with  extreme  care,  even 
paring  the  edges  of  the  wound  and  bringing  the  parts 
together  by  silver  sutures,  so  as  to  ensure  union  by  the 
first  intention.  The  object  of  this  course  being  to  re- 
tain the  blood  within  the  cavity  of  the  pleura,  allow- 
ing it  to  fill  this  space,  compress  the  lung,  and  with  it 
the  bleeding  vessel,  so  as  to  stop  the  further  loss  of 
blood.  Should  the  rapid  accumulation  of  blood  in  the 
cavity  of  the  chest  cause  serious  dyspnoea,  the  orifice 
may  require  opening  to  allow  the  fluid  to  escape,  and 
thereby  relieve  the  pressure  upon  the  lung. 

The  effect  of  this  escape  of  blood  from  the  cavity 
of  the  chest  was  exemplified  in  the  case  of  Major 
Wheat,  who  was  shot  through  the  chest  at  the  first 
Battle  of  Manassas,  the  hall  entering  in  atone  armpit 
and  escaping  from  the  other  on  a  level  with  the  nip- 
ple. Soon  hemorrhage  caused  great  oppression  and, 
finally,  fainting.  When  he  partially  recovered  his 
consciousness  he  found  himself  surrounded  by  his  men. 
who,  believing  him  dead,  had  Btripped  his  body  of 
every  vestige  of  rank,  so  as  to  prevent  recognition  by 
the  enemy.  One  of  his  men  (a  powerful  sergeant  |, 
determined  to  save  the  body  from  indignities,  had 
seized  the  major's  arms  at  the  wrists,  and,  with  the 
assistance  of  a  comrade,  had  slung  the  body  over  ids 
back,  drawing  the  arms  of  the  supposed  dead  man  over 
each  shoulder,  and   in   this  position  started  off  from 


.;_'•'»  TREATMENT    IN    OH  EST    WOUNDS. 

the  battle-field.  Major  Wheat  was  himself  a  power- 
ful man,  and  his  weight,  in  addition  to  his  chest  being 

drawn  forcibly  against  the  broad  back  of  bis  sergeant, 
80  increased  the  pressure  upon  his  lungs  as  nearly  to 
extinguish  the  flickering  spark  <>t'  remaining  life,  when 
ho  suddenly  felt  a  gush  of  blood  and  air  from,  both 
armpits,  followed  by  sueli  immediate  relief  that  he 
found  his  breath  returning,  and  when  lie  reached  the 
ambulance  wagon  he  could  stand  up.  Arriving  at  the 
hospital,  he  found  that  he  had  so  far  recovered,  under 
this  rough  treatment,  that  he  could  walk  with  assist- 
ance. Quiet,  with  but  little  medication,  soon  com- 
pleted the  cure,  and,  in  course  of  time,  enabled  the 
major  to  resume  his  command. 

In  drawing  off  the  contents  of  the  chest,  should 
syncope  threaten  we  should  close  the  opening  ami 
await  another  opportunity.  The  collection  is  retained 
in  certain  cases,  when  no  marked  dyspnoea  exists,  for 
the  purpose  of  retarding  and  finally  controlling  the 
bleeding,  by  the  pressure  which  the  pent-up  fluid 
exercises  upon  the  lung  and  its  injured  blood-ves- 
sels. After  the  third  or  fourth  day,  the  tendency  to 
hemorrhage  having  ceased,  and  the  wound  having  al- 
ready commenced  to  suppurate,  t  he  adhesive  plaster  is 
removed  ami  the  effusion  is  allowed  to  escape.  If  air 
has  been  admitted  into  the  cavity  the  exuded  blood 
has  decomposed,  and,  mingled  with  serum  and  pus, 
makes,  for  the  first  few  days,  a  copious  and  very 
offensive  discharge.  Gradually  the  escaping  fluid 
loses  its  dark  color  and  offensive  smell,  and  assumes 
the  appearance  of  healthy  pus.  Formerly  much  care 
was  taken  to  favor  the  flow  of  fluids  from  the  chest, 
and  dilation  of  the  wound  was  the  recognized  rule; 
now,  unless  serious  oppression  of  breathing  exists, 
threatening  suffocation,  the  opposite  treatment  is  the 


TREATMENT    IN    CHEST    WOUNDS.  327 

one  urged,  to  exclude  air,  and,  if  possible,  retard  de- 
composition— as  this  deterioration  of  the  effused  fluids 
is  more  injurious  to  the  sj'stem  than  the  advantages 
obtained  by  their  ready  escape.  From  this  time  on- 
ward, simple  water  dressing  will  be  the  only  local 
treatment  required  for  the  wound," 

If  the  orifice  from  a  punctured  wound  has  healed, 
with  escaped  blood  remaining  within  the  chest,  the 
collection,  if  small,  should  be  ignored,  as  it  will  gradu- 
ally be  absorbed.  If  the  extravasation  be  very  ex- 
tensive, particularly  if  air  had  previously  entered  the 
cavity,  it  may  be  necessary,  in  a  few  rare  instances, 
to  withdraw  the  effusion  by  making  a  puncture  at 
the  most  dependent  portion  of  the  chest.  This  opera- 
tion, unless  called  for  by  urgent  or  distressing  symp- 
toms,  should,  in  no  ease,  be  hastily  performed,  but 
should,  on  the  contrary,  be  delayed  as  long  as  possible. 

In  collapse  we  have  already  recognized  a  valuable 
aid  for  cheeking  hemorrhage,  and  its  remediable  ad- 
vantages should  be  appreciated.  As  a  S}Tmptom  it 
must  be  carefully  watched,  and  should  it  threaten  to 
stop  the  action  of  the  heart,  external  stimulation  must 
be  freely  used;  but  the  internal  stimuli  must  be  admin- 
istered only  in  small  quantity,  and  with  caution. 

European  writers  on  the  subject  of  chesl  wounds 
agree  that  the  lancet  is  the  only  safe  reliance  in  eases 
of  dyspnoea,  or  internal  hemorrhage,  and  they  urge 
that,  in  the  incipient  treatment,  before  the  patient  is 
borne  from  the  battle-field  by  the  litter-carriers,  the 
veins  of  both  arms  should  be  opened  and  blood  be  al- 
lowed to  run  off  freely,  which  they  consider  as  the  bes| 
means  of  Stopping  the  effusion  within  the  thoracic  cav- 
ity. This  venesection  they  do  nut  hesitate  to  repeal 
whenever  dyspnoea  -hows  itself,  and  recommend  that, 
to  obtain  its  beef  results,  il  should  be  carried  to  syncope. 


TREATMENT    IN    CHE8T    WOUNDS. 

In  connection  with  this,  the  most  active  antiphlogistic 
treatment  is  instituted.  The  results  reported  by  them 
indicate  that  tins  injury  is  among  the  most  fatal  of 
gunshot  wounds.     Of  four  hundred  and  seventy-four 

cases  reported  by  Mel d  of  injuries  to  the  chest,  one 

hundred  and  twenty-six  died,  which  is  a  frightful  mor- 
tality, when  it  is  taken  into  consideration  that  all 
wounds  about  this  region  were  included,  only  a  small 
proportion  being  perforating  wounds  with  injury  t<> 
the  lungs.  Among  the  officers  there  were  fifty-four 
cases  of  chest  wounds,  of  which  twenty-one  had  ap- 
parently perforated  the  cavity.  Of  those  latter  fifteen 
died — a  mortality  of  71  per  cent.  In  our  expedience 
perforating  wounds  of  the  chest,  even  those  in  which 

the    ball     had    clearly    travelled    the    lung,   are.   by   no 

means,  so  fatal  an  injury  a-<  ganshot  wounds  of  other 
regions   of  the    trunk.     Under  the   expectant    plan, 

which  consists  of  little  more  than  careful  nursing, 
avoiding  all  active  treatment,  more  especially  hlood- 
Letting,  we  have  succeeded  in  Bavin g  the  majority  of 
our  wounded.  Burgeon  Thoin,  in  a  recent  report  to 
the  association  of  army  ami  navy  surgeons,  gives  a 
list  of  seventy. i'mim-  cases  of  ganshot  wounds  perforat- 
ing the  chest  and  transfixing  the  lungs,  as  reported 
by  Confederate  army  surgeons.  Of  these  twenty  died 
— a  mortality  of  25  per  cent., —  which  indicate-  clearly 

the  advantages  of  the  expectant  course  of  treatment 

for  this  as  well  as  for  all  gunshot  wounds,  over  the 
heroic  and  fatal  treatment  of  former  years.  As  far 
as  could  he  ascertained,  bloodletting  had  beon  resorted 

to  in  hut  one  case  of  perforated  chest  wound. 

When  the  immediate  dangers  have  passed,  the  next 

in  order  is  inflammation  of  the  lungs  and  pleura. 
Neither  of  these  conditions  differ  in  any  very  material 
respect  from  the  idiopathic  varieties  of  tho  disease. 


TREATMENT    IN    CHEST    WOUNDS.  320 

except  that  traumatic  pneumonia  is  usually  circum- 
scribed to  narrow  limits.  As  the  cause  of  pleuritis  is 
a  direct  injury  to  the  membrane,  and,  in  the  majority 
of  instances,  as  air  has  been  admitted  within  the  cavity, 
the  effusions  which  accompany  the  inflammation  soon 
become  purulent,  and,  in  time,  false  membranes  of  con- 
siderable thickness  line  the  inner  surface  of  the  ribs. 

Thp  treatment  for  either  pneumonia  or  pleurisy, 
when  occurring  from  a  gunshot  wound,  does  not  differ 
from  the  treatment  of  the  disease  from  any  other 
cause.  McLeod's  experience  is  in  favor  of  early,  ac- 
tive, and  repeated  bleedings,  with  cool  drinks  and  ab- 
stemious diet,  recognizing,  at  the  same  time,  however, 
that  many  excellent  recoveries  have  been  mado  with- 
out recourse  to  the  lancet.  Guthrie  uses  the  lancet, 
which  he  designates  the  first  and  most  essential  remedy, 
and  which  he  says  should  be  resorted  to  in  every  case. 
The  venesection,  which  he  repeats  whenever  the  in- 
flammatory symptoms  sIioav  an  increase,  is  vigorously 
followed  by  large  doses  of  tartar  emetic  in  pneumonia, 
and  calomel  in  pleurisy — the  object  being  to  affect  the 
gums  as  soon  as  possible.  This  is  the  treatment  of  the 
old  school,  which  recent  experience  does  not  uphold. 
Guthrie  states  "That  in  the  Crimea  bloodletting  had 
not  been  so  favorably  viewed,  nor  found  so  serviceable, 
nor  so  neoessary."  Fraser,  from  Crimean  experience, 
states  that,  in  the  prevention  and  reduction  of  inflam- 
matory action,  in  perforating  wounds  of  the  chest, 
venesection  is  not  demanded.  He  advises  its  use  only 
when  the  pulse  is  full,  strong,  and  labored — a  condition 
not  often  met  with.  When  the  heart  and  pulse  are 
both  weak — a  common  condition  after  severe  wounds 
— in  our  experience  the  abstraction  of  blood  will 
sion  a  complete  prostration  of  strength,  and  may  be 
fatal 

Bb 


TREATMENT    IN    CHEST    WOUNDS. 

There  is  no  reason  for  changing  the  plan  of  treat- 
ment, already  discussed  in  detail,  for  combating  inflam- 
mation following  gnnshol  wounds,  and  which  is  equally 
applicable  to  chest  wounds.  Even  when  the  lung  is 
inflamed,  we  prefer  the  mild,  antiphlogistio  and  ex- 
pectant treatment  i<>  tin'  spoliative.  The  large  suc- 
i)  the  treatment  of  perforating  chest  wounds  in 
the  Confederate  hospitals  puts  forth,  in  a  Btrong  light, 
the  powers  of  nature  to  heal  all  wounds  when  least 
interfered  with  by  meddlesome  Burgery.  Absolute 
rest,  cooling  beverages,  moderate  nourishment,  avoid- 
ing over-stimulation,  with  small  doses  of  tartar  emetio, 
veratrum,  or  digitalis,  the  liberal  use  of  opium,  and  at- 
tention to  the  intestinal  Becretions,  will  be  required  in 
all  cases,  and  in  most  will  compose  the  entire  treat- 
ment. 

A  certain  degree  of  pleuritis  is  expected  and  d<  - 
in  penetrating   lung  wound.-,  to  establish   adhesions 

between  the  injured  lung  and  thoracic  wall,  which  will 
at  once  isolate  the  injured  part,  and  prevent  inflam- 
matory sequela).  As  gunshot  wounds  do  not  usually 
close  rapidly,  but  suppurate,  often  permitting  the  ac- 
cess of  air  within  the  thorax,  the  suppuration  may  he 
profuse  and  long-continued.  We  must  remember  this 
in  the  treatment,  and  not  use  depressing  agents. 
When  the  pleuritis  is  excessive  and  general,  both  false 
membranes  and  the  rapid  accumulation  of  fluid  are  to 
be  anticipated.  If  the  external  wound  isstill  open,  the 
position  in  which  the  body  is  placed  is  very  important, 
as  it  will  allow  of  the  ready  escape  of  the  effusion, 
which  is,  at  first,  serous,  but   Boon  becomes  purulent. 

Position  and  constitutional  support  will  form  the  basis 
of  treatment.  lithe  pus  could  have  a  constant  outlet 
for  escape,  and  accumulation  within  the  cavity  could 
be  prevented,  the  false  membranes  would  tie  the  lung 


TREATMENT    OF    FRACTUftEfc    RIBS.  331 

to  the  thoracic  Avail  at  an  early  period,  and,  by  oblit- 
erating the  affected  portion  of  the  pleural  cavity,  pre- 
vent further  discharge.  Should  the  wound  from  which 
pus  pours  daily  be  in  the  upper  portion  of  the  chest, 
and  auscultation  and  percussion  indicate  that  the  entire 
cavity  is  filled  with  fluid,  it  would  hasten  the  cure  to 
establish  a  counter-opening  from  the  most  dependent 
portion  of  the  cavity,  by  which  the  drain  would  be 
facilitated. 

The  chapter  on  the  treatment  of  suppurating  wounds 
lays  down  general  laws  for  counteracting  the  inju- 
rious influences  of  long-continued  suppuration. 

Penetrating  wounds  of  the  thorax  occasionally  re- 
main fistulous  for  an  almost  indefinite  period — which 
is  caused  by  a  failure  of  general  adhesion  between  the 
costal  and  pulmonary  pleura*.  A  kind  of  pouch  is 
found,  lined  by  a  false  membrane,  from  which  a  puru- 
lent lymph  is  continually  secreted.  After  empj^ema 
the  chest  contracts,  the  walls  sink  in,  the  diaphragm 
rises  high  on  the  affected  side,  the  spine  becomes  con- 
torted, air  enters  indifferently  into  the  lung,  ausculta- 
tion indicates  no  respiratory  murmur,  little  or  no 
respiratory  movements  are  seen  in  the  chest,  and  a 
portion  of  the  respiratory  apparatus  is  rendered  useless 
to  the  economy.  Usually  this  long  train  of  symptoms 
terminate  fatally  in  phthisis, although  in  the  progress 
of  ordinary  gunshot  wounds  of  the  chest  and  lungs 
perfect  health  is  regained  in  the  majority  of  cases. 

In  cases  of  fractured  ribs,  from  gunshot  injuries, 
which  is  a  very  frequenl  complication  of  perforating 
wounds  of  the  chest,  the  bone  is  usually  spiculated, 
and  some  of  the  fragments  may  accompany  the  ball  in 
its  onward  course.  Upon  examination  with  the  finger 
irregular  fragments  can  bo  detected,  and  should 
be  removed.     If  necessary,  the  outer  wound  might  be 


TRKATMF.NT    OF    FRACTURED    U 

enlarged,  to  facilitate  this  importanl  step.  The  danger 
i<  do(  bo  much  from  the  breaking  of  the  bone,  bat  from 
the  displaced,  sharp  fragments  seriously  injuring  the 
pleura  and  Lang.  Where  the  ball  has  fractured  the  rib 
without  perforating  the  cavity,  the  digital  examina- 
tion should  be  made  With  extreme  caution,  so  as  not  to 
force  Bharp  spiculaj  through  the  pleural  lining,  thereby 
converting  a  simple  into  a serious  accident.  When  these 
are  removed  the  wound  should  be  closed  with  a  wide 
adhesive  strap,  and  cold  water  dressings  applied. 
Whether  symptoms  indicate  injury  to  the  lung  or  not, 
a  broad  band  must  be  applied  and  firmly  drawn 
around  the  chest,  in  order  to  control  the  thoracic 
movements  and  allay  the  pain.  This  pain  is  caused 
chiefly  by  the  movements  of  the  broken  ribs  driving 
the  sharp  fragments  into  the  sensitive  tissue.  <  iontrol 
the  movement  by  a  broad  bandage,  and  pain  is  at 
once  relieved.  An  opening  is  made  in  the  broad  hand 
to  correspond  with  the  wound,  so  that  the  discharge 
can  esoape  freely  without  interfering  with  the  fracture 
dressing.  Where  the  spiculaj  are  not  displaced,  a 
broad  adhesive  strap  is  the  only  local  apparatus  re- 
quired. Necrosis  of  the  rib  commonly  follows  a  gun- 
shot  fracture,  and  may  require  a  subsequent  operation 
for  its  removal. 

When  an  intercostal  artery  is  divided  the  bleeding 
point  will  be  discovered  bydrawingoul  the  lips  of  the 
wound    with  a   tenaculum,  when   the  vessel   should   he 

secured.  All  military  Rurgeons  agree  thai  this  is  an 
operation  more  frequently  spoken  of  than  performed, 
many  of  extensive  experience    having  never  seen  a 

case. 

When  foreign  bodies,  as  halls,  pieces  of  hone,  cloth, 
wadding,  etc.,  are  driven  into  the  pleural  cavity,  unless 
remoYed,  they  may  produce  fatal  results  by  inflamma- 


GUNSHOT    WOUNDS    OF    SPINE.  333 

tion  and  exhausting  discharges.  A  loose  ball  can  bo 
sometimes  felt  by  the  patient,  and  its  movements  often 
detected  by  the  stethescope.  Through  an  opening, 
made  at  the  most  dependent  portion  of  the  chest,  the 
foreign  body  has  been  successfully  removed. 

Among  the   most  fatal  injuries  are  found  gunshot 
wounds  of  the  spine,  whether  inflicted  by  shot  or  por- 
tions of  shell.     A  concussion  of  the  spinal  cord,  pro- 
duced by  the  explosion  of  a  shell  in  the  immediate 
vicinity  of  the  back,  is   an  injury  not  unfrequently 
met  with  in  field  practice,  having,  as  its  most  con- 
spicuous symptom,  pain  in  the  vicinity  of  the  injured 
part,  accompanied   by   impairment   of  mobility   and 
sensation  of  the  lower  limbs,  amounting  at  times  to 
paralysis.     These  annoying  conditions  are  very  per- 
sistent— patients  thus    afflicted  being  often    the   in- 
mates of  military  hospitals  for   months.     As  the  re- 
sult of  such  a  concussion,  blood  may  be  effused  within 
the  sheath  of  the  cord,  causing  a  similar  paralysis  from 
pressure  as  was  seen  in  hemorrhage  within  the  skull. 
A  chronic  and  eventually  fatal  myelitis  may  supervene 
upon    this   extravasation,   increasing   and   extending 
the  paralysis  so  as  to  include  the  bladder  and  rectum, 
With   involuntary   escape   of  feces   and    retention    of 
urine.     The  inflammation  may  run  on  to  complete  dis- 
organization of  the  cords.     The  treatment  from  which 
relief  will  be  obtained  is  in  keeping  the  patient  per- 
fectly quiet  in  the  recumbent  position,  using  blisters 
or  cups  to  the  back,  and  applying  stimulating  embro- 
cations to  the  spine.     The  urine  should  be  drawn  off 
twice  daily.     When  the  bladder  is  paralyzed  and  the 
rectum  emptied  daily  by  an   enema,  so  as  to  prevent 
the  continued  escape  Of  small  quantities  of  fecal    mat- 
te!', extrad  of  belladonna,  in  half-grain  doses,  is  sup- 
posed   to  exercise's  decided   influence  in  controlling 


kIPTOMS    OS    WOUNDS   01    SPINK. 

stions  of  the  spinal  cord,  and  may  be  used  with 
benefit.  When  the  Bymptoms  ai*e  slowly  (subsiding, 
the  only  remaining  evidence  of  injury  being  the  de- 
bility of  the  lower  limbs,  convalescence  can  be  hast- 
ened by  the  internal  use  of  sulphate  of  strychnia. 

'L'li'  ,u  which  balls  embed  themselves  in  the 

bodies  of  the  vertebra  without  injury  to  the  cord  are 
not  bo  dangerous,  although  a  weakness  of  the  baok, 
with  severe  pains  similating  rheumatism,  torment  the 

patient,  and  may  eventuate  in  serious  derangement  of 
the  economy. 

All  gunshot  wounds  of  the  spinal  column  do  not 
destroy  life  with  the  same  rapidity,  although  they  are 
all  considered  necessarily  fatal.  By  examining  the 
anatomical  distribution  of  the  many  nerves  which  take 
their  origin  from  this  nervous  centre,  we  will  find  that 

many   of  the  important  Organs  Of  the   trunk   are   Mip- 

plied  from  this  source.  I  lommencing  from  above,  after 
the  muscles  of  the  neck  are  supplied,  arc  the  phrenic 
nerves,  which  give  motion  to  the  diaphragm.  They 
arise  from  the  vicinity  of  the  third  cervical  vertebra. 
Prom  the  lower  cervical  region  originate  the  nen 
the  upper  extremity ;  from  the  dorsal  region  the  inter- 
costal muscles  receive  their  nervous  supply j  ami  from 
the  lumbar  region,  besides  the  muscles  of  the  lower 
pari  of  the  trunk  and  those  of  the  lower  limbs,  the 
bladder  ami  rectum  are  dependent  for  their  powers  of 
action  upon  nerves  originating  here. 

Should  a  fragmonl  of  -hell  or  a  hall  lay  open  the 
lower    portion    of   the    .spinal    column,    the    immediate 

symptoms    would    he   paralysis   of  the    lower  limbs, 

with    retention    of   urine    and    involuntary   discharges 

of  feces, inasmuch  as  there  is  no  power  in  the  sphinc- 
ter  muscles  Of  the  anus  to  retain    the  contents  of  the 

rectum.     The  surface  of  the  lower  portion  of  the  body 


SYMPTOMS    OF    WOUNDS    OF    SPINE.  335 

and  extremities  loses  temperature,  and  with  it  a 
gradual  impairment  of  nutritive  activity,  in  which 
the  entire  economy  in  time  sympathizes.  The  skin 
of  the  paralyzed  portion  assumes  a  cadaveric  hue, 
with  tendency  to  congestion  at  different  points,  even- 
tuating in  a  lifting  of  the  cuticle  and  a  gangrenous 
condition.  Should  the  patient  survive  sufficiently  long, 
mortification  attacks  all  thoso  paralyzed  portions  of 
the  body  compressed  in  the  attitude  of  lying,  and  im- 
mense sloughing  bed  sores  assist  to  exhaust  the  patient. 
While  these  changes  are  going  on,  some  of  tho  con- 
tents of  the  over-distended  bladder,  filled  with  decom- 
posed urine,  is  constantly  escaping — there  being  no 
power  in  the  paralyzed  neck  of  the  bladder  to  retain 
it.  The  urine  becomes  alkaline  and  ammoniacal,  irritat- 
ing the  mucus  lining  of  the  bladder,  which  assumes 
a  condition  of  chronic  inflammation,  with  thick,  ropy 
discharges.  Should  not  inflammation  and  disorganiza- 
tion of  the  spinal  cord  occur  to  destroy  life  more  rap- 
idly, the  patient  may  live  for  weeks  or  months,  but  is 
graduall}'  worn  out. 

Where  the  injur}'  to  the  spine  is  located  in  the 
dorsal  region,  there  are  present,  besides  the  symptoms 
just  enumerated,  paralysis  of  the  abdominal  muscles, 
and  all  those  intercostal  muscles  situated  below  the 
seat  of  injury.  This  complication  interferes  more  or 
less  seriously  with  respiration,  which  meets  with  no 
assistance  from  the  abdominal  and  intercostal  muscles, 
but  must  be  carried  on  solely' by  mean-  ->t  the  dia- 
phragm, the  thoracic  cavity  h.inu-  contracted  by  the 
depressed  ribs.  In  consequence  of  this  paralysis,  res- 
piration and  the  artrrializat i<>n  of  the  blood  is  \<vy 
indifferently  performed.  Congestion  of  the*  lungs  is 
gradually  induced,  and  tho  patient  rarely  survived 
this  accident    more    than    from   two    to   three   weeks, 


33(5  TREATMENT   Of   SPINAL    INJURIES. 

although  he  is  usually  carried  ofl'a  few  days  after  the 
reeeipt  of  the  wound.  As.  the  point  of  injury  ascends, 
the  spinal  cord  involving  the  upper  extremities,  the 
respiratory  movements  are  more  embarrassed,  and 
should  tho  injury  be  Located  in  the  vicinity  of  the 
third  cervical  vertebra,  and  at  the  origin  of  the  nerves 
supplying  the  diaphragm,  death  is  immediate  from 
asphyxia,  as  all  respiratory  movements  are  completely 
paralyzed. 

In  any  case  of  gunshot  injury  of  the  spinal  column, 
even  in  its  lower  portion,  should  inflammation  of  the 
cord  and  its  meninges  be  established,  which,  when  it 
occurs,  ordinarilj'  makes  its  appearance  four  or  five 
days  after  the  receipt  of  injur}-,  death  occurs  speedily 
from  the  disorganizing  effects  of  this  inflammation. 
Where  the  spinal  cord  has  been  injured  by  a  ball  <>r 
portion  of  shell,  the  patient  dies,  no  course  of  treat- 
ment offering  any  prospects  of  success.  The  course 
to  be  pursued  is  altogether  palliative — keeping  the. 
bowels  and  bladder  emptied,  and  allaying  pain  by 
administering  some  of  tho  preparations  of  opium. 
This  class  of  injuries  is  by  far  the  most  fatal  of  all 
gunshot  wounds. 


CHAPTER    XI. 

Wounds  or  Abdomen — Flesh  Wounds — Never  probe  perforating 
Wounds  of  the  Abdomen,  and,  especially,  never  attempt  to 
BBARCH  for  Foreign  Bodies  which  have  passed  beyond  the  Ab- 
dominal Walls — Sew  up  Intestinal  Wounds — Dilate  Wound  in 
Abdomen  when  necessary  to  relieve  strangulation  and  to  fa- 
cilitate reduction — AVhere  the  larger  Viscera  are  injured, 
recovery  is  rare — Avoid  using  Purgatives  when  the  Intestine 
is  wounded — Peritonitis  a  common  causeof  Mortality — Where 
the  Intestine  is  much  crushed,  leave  it  out  of  the  Wound,  or 
excise  the  crushed  portion,  and  close  the  intestinal  wound 
by  Sutures — In  wounds  of  the  Bladder,  continued  use  of 
Catheter  essential. 

Sir  Charles  Bell  has  remarked  that,  although  ab- 
dominal wounds  boi-c  a  fair  relative  proportion  toother 
wounds,  immediately  after  a  battle,  a  few  days  suf- 
ficed to  remove  them — so  that,  by  the  end  of  the  first 
Week,  there  was  scarcely  one  to  be  seen.  This  rule  is 
only  partially  verified  in  modern  surgical  experience, 
as  many  cases  of  intestinal  wounds  recover.  In  cases 
of  perforating  wounds  of  the  abdomen,  those  Avho  have 
received  wounds  of  the  large  abdominal  viscera,  such 
as  the  liver,  stomach,  kidneys,  and  bladder,  are  most 
frequently  lost — t  he  exceptions  of  restoration  to  health 
being  not  very  numerous.  Like  wounds  of  the  chest, 
where  the  abdominal  walls  are  not  perforated,  bu1  the 
entire  traek  of  the  hall  lies  in  the  thickness  of  the 
muscles,  the  wound  is  simply  a  flesh  wound,  of  a  com- 
paratively trivial  character,  and  should  be  treated  ac- 
cordingly. Tin-  track  Of  the  hall  may  not  always  he 
in  a  straight  coane,  as  the  muscles,  or  their  ten'1' 


338  ABDOMINAL    WOUNDS. 

portions,  when  in  action,  offer  sufficient  resistance  to 
divert  the  ball. 

A  perforating  wound  of  the  abdomen  is  equally  dan- 
gerous with  those  of  the  chest,  as  peritonitis  is  apt  to 
supervene.  If  the  perforation  be  made  by  a  sword  or 
bayonet,  or  if  there  be  any  prospect  of  healing  by  the 
first  intention,  the  wound  should  be  accurately  closed 
by  adhesive  straps  or  by  sutures.  In  sewing  up  an 
incised  abdominal  wound,  many  recommend  that  the 
needle  should  not  pass  deeper  than  the  superficial 
cellular  tissue — giving,  as  a  reason,  that  when  the 
muscles  are  included  in  the  sutures  they  sometimes 
draw  themselves  out  of  the  noose  by  their  contrac- 
tion, while,  if  the  peritoneum  be  also  included,  perito- 
nitis is  likely  to  occur  from  the  irritation  of  the 
thread.  Although  this  may  hold  good  in  theory,  it 
is  not  verified  by  experience.  There  is  no  reason 
why  attempts  should  not  be  made  to  cause  union 
throughout  the  entire  thickness  of  the  abdominal 
wall,  and,  therefore,  all  the  tissues  should  be  included 
in  the  suture.  When  this  is  done,  the  cicatrix  will  be 
firmer,  and  there  will  be  less  probability  of  secondary 
hernia — a  very  common  accident  after  injury  to  the 
abdominal  walls. 

In  probing  abdominal  wounds,  the  only  object  to  be 
sought  by  the  examination  is,  whether  the  wound  has 
perforated  the  cavity  or  not  ?  From  the  direction  of 
the  track,  this  can  nearly  always  be  determined.  In 
this,  as  in  any  other  gunshot  wound,  the  use  of  the 
silver  probe  would  be  very  dangerous,  as  it  may  con- 
vert a  simple  into  a  perforating  wound.  By  means  of 
the  finger,  or  a  gum  bougie,  the  course  of  the  wound 
can  be  traced,  and  also  the  existence  of  foreign  bodies 
detected.  Should  we  find  that  the  opening  transfixes 
the  abdominal  wall,  our  examination  should   go  no 


RETURN    PROTRUDING    VISCERA.  339 

further.  It  is  a  dangerous  amusement  to  satisfy  curi- 
osity at  the  expense  of  such  irreparable  mischief  as 
may  destroy  the  life  of  the  patient. 

If  the  wound  be  a  large  one,  as  when  made  by  a 
bayonet,  fragment  of  a  shell,  or  minie  ball,  a  portion 
of  the  abdominal  contents  may  protrude  from  the 
wound.  This  is  not  a  serious  complication  if  the 
viscera  be  not  injured.  When  the  ambulance  surgeon 
finds  such  a  case  on  the  field,  his  first  duty  will  be  to 
examine  the  protrusion.  If  it  be  a  portion  of  small 
intestine,  and  be  not  injured,  he  cleanses  it  of  dirt  or 
other  extraneous  substances  by  pouring  water  upon 
it;  and,  carefully  returning  it  within  the  abdomen, 
closes  the  wound  by  sutures,  if  it  be  an  incised  wound, 
or  a  broad  strip  of  diachylon  plaster,  if  a  gunshot 
wound.  He  then  administers  a  dose  of  morphine,  and 
sees  that  the  wounded  man  is  properly  transported  to 
the  field  infirmary. 

To  facilitate  the  return  of  the  protrusion,  whether 
it  be  intestinal  or  omental,  the  patient  is  placed  upon 
his  back,  with  the  thighs  drawn  up  and  the  abdominal 
muscles  relaxed,  when  the  surgeon  makes  steady 
pressure  upon  the  protrusion  in  the  direction  of  the 
wound.  The  bowel  must  be  handled  very  carefully — 
no  force  should  be  used,  or  so  much  injury  might  be 
inflicted  as  to  cause  the  rupture,  sloughing,  or  inflam- 
mation of  the  protruding  organ.  The  better  plan 
would  be  to  encircle  the  protrusion  by  the  fingers 
clustered  together  as  a  funnel  or  cone,  which  will 
diminish  the  bulk  at  the  opening  in  the  abdomen, 
and  facilitate  its  return. 

If  it  be  found  that  the  mass  is  so  constricted,  by  the 
small  size  of  the  orifice,  that  the  return  within  the 
abdominal  cavity  is  impossible  without  inflicting  in- 
jury upon  the  bowel,  the  intestine  should  be  drawn  to 


340  RETURN    PROTRUDING    VISCERA. 

one  side,  arid,  using  great  caution,  the  wound  should 
be  enlarged  a  quarter  or  half  an  inch,  as  the  injury  in- 
flicted in  the  abdominal  walls  by  the  knife  would  be 
of  small  moment,  when  compared  to  the  bruising  of 
tho  protruding  viscera  from  the  force  necessary  to 
push  it  through  the  small  opening. 

Cutting  upon  a  grooved  director,  or  using  a  probe- 
pointed  bistoury,  while  enlarging  the  wound,  will 
diminish  the  dangers  of  injuring  some  important  part 
within.  The  return  of  the  bowel  should  always  be 
effected  by  the  ambulance  surgeon  before  the  case  is 
transported  to  tho  field  infirmary,  inasmuch  as  the 
crowding  of  the  wounded  at  the  infirmary  may  be  such, 
that  several  hours  might  elapse  between  the  receipt 
of  injury  and  the  hospital  examination — quite  long 
enough  to  cause  strangulation  of  the  intestine,  and 
sufficient  to  excite  cither  inflammation  or  mortification 
of  the  protrusion,  usually  a  fatal  complication  in  ab- 
dominal wounds. 

The  early  return  of  the  protruding  intestine  makes 
the  case  one  for  simple  and  successful  treatment.  Bo 
satisfied  that  the  intestine  has  been  returned  within 
tho  abdominal  cavit}r  and  not  forced  under  the  sheaths 
of  the  abdominal  muscles,  where  it  would  strangulate 
and  rapidly  destroy  life. 

Should  the  case  not  bo  seen  until  several  hours  had 
elapsed,  the  intestine  should  be  equally  returned, 
whether  it  be  blackened  by  congestion  or  be  inflamed; 
but  when  gangrenous,  which  is  recognized  by  its 
greenish  ash  color,  loss  of  polish,  its  flaccid  condition, 
with  already  a  disposition  to  separation  in  its  various 
coats,  it  should  remain  without  the  wound,  and  be  laid 
open  so  as  to  allow  its  fecal  contents  to  bo  evacuated. 
Adhesions  rapidly  form,  uniting  the  protruded  intes- 
tine to  the  peritoneum  at  the  inner  orifice  of  the  wound. 


TREATMENT    OF   PUNCTURED    INTESTINES.  341 

This  shuts  off  all  connection  with  the  peritoneal  cavity, 
and  prevents  extravasation  of  fecal  matter  within  it. 
If  the  bowel  be  returned  in  a  mortified  condition,  the 
contents  of  the  bowel  would  be  discharged  into  the 
peritoneal  cavity,  and  fatal  peritonitis  Avould  be  ex- 
cited. 

Should  the  intestine  be  punctured,  it  should  be 
closed  with  one,  two,  or  more  points  of  interrupted 
suture,  according  to  the  size  of  the  opening — a  stitch 
being  placed  for  every  one-sixth  of  an  inch  of  intestinal 
wound.  The  ends  of  the  suture  are  cut  off  close  to 
the  knot,  and  the  bowel  is  returned  with  care  into  the 
abdomen.  A  fine  cambric  needle  will  be  the  best  in- 
strument for  sewing  up  intestinal  wounds,  as  the  small 
puncture  and  fine  thread  produce  but  little  irritation. 

It  would  be  better  to  avoid  perforating  the  mucus 
lining  of  the  bowel  in  passing  the  sutures  5  but  should 
the  entire  thickness  of  intestinal  wall  be  transfixed  by 
the  needle,  the  pouting  mucus  surface  must  be  pushed 
in  from  between  the  lips  of  the  intestinal  opening,  so 
that,  in  drawing  the  noose  of  the  suture,  the  perito- 
neal surfaces  will  be  turned  in  and  brought  in  contact 
upon  each  side  of  the  wound,  when  rapid  adhesion  will 
take  place.  As  the  mucus  surface  is  lined  by  an  epith- 
lium,  its  presence  between  the  lips  of  the  wound  would 
prevent  union.  During  the  process  of  healing,  an  ex- 
cess of  lymph  is  deposited,  which  accumulates  over  the 
suture,  incarcerating  the  knot.  Finally  the  thread  is 
thrown  off  into  the  bowel,  having  disengaged  itself  by 
ulcerating  through  the  mucus  membrane.  This  is  a 
very  beautiful  provision  of  nature,  for,  should  the 
thread  escape  into  the  peritoneal  cavity,  fatal  inflam- 
mation would  most  probably  ensue. 

If  a  large  dose  of  opium  had  been  administered  on 
the  battle-field,  or  as  soon  as  the  patient  had  arrived 


•°.1_'  TREATMENT    OF    PUNOTUBED    iv, 

at  the  infirmary,  while  awaiting  his  turn  t<>  be  dre 
the  peristaltic  action  of  the  bowels  would  have  been 
suspended,  and  the  wounded  portion  of  the  bowel, 
which,  when  the  hernia  ie  extensive,  should  always  be 
the  last  portion  returned,  remains  within  the  abdomi- 
nal  cavity,  in  immediate  contact  with  the  wound ;  and 
to  this  point  it  soon  becomes  attached  throhgh  adhe- 
sive inflammation.  Should,  from  any  oau8e,thesu1  ores 
give  way.  or  the  bowel  slough  from  the  injury  which 
it  had  received,  its  Contents,  instead  of  being  thrown 
into  the  peritoneal  cavity  where  it  would  produce  fatal 
inflammation,  would,  on  account  of  the  adhesions  of 

the   bowel    near  an    external  outlet,  escape  externally, 

which  diminishes  materially  the  risk  run  by  the  patient. 
The  threads  used  in  closing  the  opening  in  the  intes- 
tine, under  these  circumstances,  either  escape  through 
the  bowel  by  stool,  or  are  discharged  through  the 
abdominal  wound. 

In  examining  the  external  wound  when  no  protru- 
sion exists,  should  we  find  an  escape  of  fecal  matter — 
which  proves  that  the  bowel  has  been  perforated — 
some  surgeons  recommen'd  that  the  abdominal  wound 
be  enlarged,  and  the  wound  in  the  intestine  closed  by 
suture.  This  tiny  consider  the  only  expedient  for 
saving  life — for,  should  the  contents  of  the  bowel  be 
allowed  to  escape,  into  the  peritoneal  cavity,  a  fatal 
Issue  must  be  expected.  The  dilatation  of  the  wound, 
they  believe,  diminishes  the  risks. 

In  such  eases  I  would  prefer  paralysing  the  vermi- 
cular motions  of  the  intestine  by  large  and  repeated 
doses  of  opium — the  first  dose  being  administered  as 
soon  as  the  condition  of  the  wound  is  perceived,  and  the 
effects  kept  up  for  several  days  until  the  bowel  becomes 
adherent  to  the  abdominal  wall,  or  the  orifice  in  it  be- 
comes closed.      With  the  cessation  of  peristaltic  mo!  ion 


TREATMENT    OF    PUNCTURED   INTESTINES.  843 

the  escape  of  intestinal  contents  will  also  cease,  and  the 
dangers  of  inflammation,  from  a  foreign  substance  in 
the  peritoneal  cavity,  diminish.  Should  the  discharge 
continue,  it  would  likely  escape  through  the  abdomi- 
nal wound. 

Should  the  intestine  be  extensively  injured  beyond 
the  possibility  of  saving  it,  rather  than  return  a  por- 
tion of  bowel  within  the  abdomen  to  mortify  and 
destroy  the  patient,  it  should  be  left  hanging  out  of  the 
wound.  All  of  the  sound  portion  of  the  protrusion 
having  been  returned,  the  crushed  portion  is  enveloped 
in  a  wet  or  oiled  cloth.  The  peritoneal  coat  of  the 
bowel  will  form  adhesions  to  the  peritoneal  edge  of  the 
abdominal  wound,  the  outer  portion  sloughs,  ami  an 
artificial  anus  forms,  which  gives  constant  escape  to 
the  fecal  contents.  In  time  this  artificial  outlet  grad- 
ually closes  b%T  a  spontaneous  effort  of  nature,  the  feces 
seeking  their  normal  passage.  In  nearly  every  case 
of  artificial  anus  from  gunshot  wound,  the  restoration 
of  the  continuity  of  the  bowel,  with  closure  of  the 
wound,  is  effected  by  nature,  although  the  cure  may  be 
delayed  for  even  twelve  months.  Rarely  is  it  neces- 
sary to  interfere,  by  an  operation,  to  remove  the  de- 
formity. 

In  examining  the  archives  of  surgery  we  find  cases 
in  which  portions  of  the  intestines  have  been  cut  off, 
the  cylinder  of  the  bowels  reunited  by  sutures,  and 
excellent  recoveries  obtained.  These  experiments 
have  been  tried  successfully  upon  animals,  and  in- 
stances are  met  with  where  the  human  subject  has  been 
saved  by  a  similar  operation.  I  have  recently  had 
under  my  care  a  lunatic,  who,  some  months  since,  at- 
tempted suicide  by  opening  Ins  abdomen,  drawing  out 
hi-  bowels,  ami  completely  severing  two  feet  of  in- 
testine.    Dr.  Gaston,  of  Columbia,  S.  <".,  who  had  the 


.;  I  1  PERFORATING    ABDOMINAL    WOUNDS. 

case  under  charge,  brought  the  two  open  ends  of  the 
intestine  together,  and,  securing  them  l>v  carefully-ar- 
ranged sutures,  returned  them  within  the  cavity. 
The  patient  made  a  perfeel  recovery.  Tins  accident, 
which  terminated  so  successfully  for  the  lunatic,  sug- 
gests an  operation  for  a  crushed  intestine,  which  may 
offer  bettor  prospects  than  Leaving  the  bowel  to  slough 
and  form  an  artificial  anus.  In  such  eases  the  hest 
rule  for  treatment  would  consist  in  removing  the  in- 
jured portion,  securing  the  bleeding  vessels,  and  re- 
closing  the  intestine  by  sutures,  and  treating  the  case 
as  if  a  simple  incised  wound  of  the  bowel  had  alone 
existed. 

In  all  .perforating  wounds  of  the  abdomen,  as  we 
can  not  tell,  in  the  absence  of  symptoms,  whether  the 
intestines  have  been  injured  or  not,  there  are  two 
fundamental  rules  of  treatment  never  to  be  forgotten, 
and  which  are  required  in  every  instance. 

1.  Give  opium  freely  and  frequently,  with  the  double 
object,  viz:  of  controlling  the  peristaltic  action,  which 
alone  can  prevent  extravasation  of  the  contents  into 
the  peritoneal  eavity,  and  for  its  antiphlogistic  effeet, 
to  equalize  the  circulation,  allay  pain,  suspend  nervous 
irritability,  and  prevent  inflammation. 

2.  Avoid  the  use  of  purgatives,  and  enforce  abste- 
mious or  even  absolute  diet. 

In  our  hospital  experience,  gunshot  wounds,  impli- 
cating the  intestines,  give  a  mortality  of  about  25  per 
cent., — the  average  duration  of  treatment  for  the  suc- 
cessful eases  being  thirty-eight  days.  The  large  num- 
ber, proportionably,  of  cures,  depends  upon  the  class  of 
wounds,  as  many  of  the  more  serious  die  on  the  field 
before  they  could  bo  conveyed  to  a  general  hospital. 


PERFORATING  ABDOMINAL  WOUNDS.       345 

When  all  perforating  abdominal  wounds,  with  injury 
to  intestines,  are  included,  the  experience  of  field 
surgeons  gives  a  mortality  of  75  per  cent.  The  for- 
mation of  an  artificial  anus  in  the  progress  of  the  case 
should  not  be  considered  a  serious  complication,  as 
they  usually  heal  even  when  the  bowel  has  been 
wounded  in  two  or  three  places,  with  the  formation  of 
as  many  artificial  ani. 

With  the  majority  of  physicians,  who  have  had  but 
little  experience  in  the  -  treatment  of  abdominal 
wounds,  the  first  impulse  is  to  see  the  bowels  emptied, 
and  hence  the  fatal  purgative  is  eagerly  administered. 
An  evacuation  apparently  reassures  them  that  all  is 
right;  when,  on  the  contrary,  all  is  very  wrong,  as  the 
progress  of  the  case  will  soon  show  them.  This  is  a 
fatal  error,  which  the  utmost  after-care  can  not  remedy. 
For  three  or  four  clays  at  least  after  the  receipt  of  in- 
jury, in  which  the  intestines  are  known  or  are  supposed 
to  be  wounded,  absolute  rest,  the  most  abstemious  diet, 
and  the  liberal  use  of  opium  (one  grain  of  gum  opium, 
or  its  equivalent  in  laudanum,  every  six  hours),  in 
connection  with  cold  water  or  iced  dressing,  will  com- 
pose the  entire  treatment.  If  the  patient  feels  uneasy, 
an  enema  will  relieve  the  large  intestines  and  add 
much  to  his  comfort.  By  the  fourth  day  the  wound 
in  the  intestines  will  have  closed  by  lymphy  effusion, 
and  the  dangers  of  exciting  inflammation  will,  to  a 
certain  extent,  have  subsided. 

If  peritoneal  inflammation  be  excited,  with  febrile 
reaction,  pain  greatly  increased  by  pressure  over  the 
abdomen,  and  more  particularly  in  the  neighborhood 
of  the  wound,  with  tympanitis,  vomiting,  hiccup, 
small,  quick  pulse,  and  Anxiety  of  countenance,  the 
fears  are  that  lymph  and  sero-purulent  matter  will  be 
rapidly  thrown  out,  gluing  coils  of  intestines  together 


846  PERFORATING    ABDOMINAL    WOUNDS. 

and  filling  the  abdominal  cavity  with  fluid.  To  check 
this  rapidly    fatal   disorganisation,   leeches  or  cupa 

sliouhi  be  applied  to  the  abdomen,  to  be  followed  by 
hot  narcotic  or  turpentine  stupes,  by  blisters,  or  by 
ice  bladders,  which  arc  now  preferred,  while  opium 
should  be  given  in  large  doses  and  at  short  intervals. 
J  f  the  patienl  he  young  and  plel  boric,  and  the  inflam- 
matory symptoms  are  early  recognised,  the  lancet 
might  be  used;  but  as  a  rule,  in  military  Burgery,  this 
remedy  is  badl}'  borne,  and  has  been  generally  dis- 
carded. Calomel  was  formerly  used  with  the  opium, 
and  was  considered  tlte  main  dependence,  hut  is  now 
dispensed  with,  as  all  the  advantages  gained  are  ac- 
credited to  the  opium. 

Sometimes  in  a  lew  hours,  usually  at  the  end  of  the 
second  or  third  day.  collapse,  with  a  cold,  sweating 
skin,  and  feeble,  irregular  pulse,  shows  the  ravages 
which  the  system  baa  experienced  from  the  peritonea] 
inflammation,  and  marks  rapidly-approaching  dissolu- 
tion. It  is  rare  that  the  liberal  use  of  brandy,  with 
carbonate  of  ammonia,  external  warmth,  and  sin- 
apisms, rescue  the  patient  at.  this  advanced  stage; 
although,  it'  given  when  debility  commences  to  show 
itself,  they  may  supp  >rt  the  patient,  and  be  the  means 
Of  saving  life.  When  the  swelling  of  the  ahdomen, 
and  the  dull  sound  which  percussion  elicits,  shows  ex- 
tensive eil'usion.  the  abdominal  wound  should  be  ro- 
opened,  and,  by  placing  the  patient  in  a  proper  position, 
the  eil'usion  he  allowed  to  escape.  It  is  a  desperate 
operation,  but  has  been  known  to  save  a  few  cases, 
which,  if  left  alone,  would  have  certainly  perished,  as 
those  do  upon  whom  this  operation  is  not  performed. 

In  gunshot  wounds  of  the  ahdomen,  if  the  missile 
has  perforated,  it  would  he  madness  to  probe  the  ab- 
dominal  cavity.      We   must   imagine   the    worst,  give 


PERFORATING    ABDOMINAL   WOUNDS.  347 

the  patient  the  benefit  of  these  doubts,  and  by  ex- 
treme care  hope  to  counteract  the  baneful  influences 
which  foreign  bodies,  when  remaining  in  the  abdomi- 
nal cavity,  always  exercise.  The  ball  may  have  trav- 
ersed the  cavity  and  embedded  itself  in  the  fleshy 
walls  beyond,  or  even  in  the  body  of  a  vertebra, 
without  having  injured  any  organ  of  importance  in 
its  course.  The  absence  of  serious  symptoms,  as  the 
case  progresses,  can  alone  inform  us  on  this  head. 
From  the  physiological  effects  following  a  gunshot 
wound  we  might,  at  times,  trace  the  resting-place  of 
the  ball :  e.  g.,  when  paralysis  of  the  lower  limbs  fol- 
lows au  abdominal  gunshot  wound,  we  might  infer 
tin.'  burying  of  the  ball  in  the  vertebral  column,  with 
pressure  upon  the  spinal  cord,  or  an  injury  to  the 
nerves  of  the  extremity  as  they  emerge  from  the 
spine,  etc. 

Should  the  abdominal  wound  bleed  profusely,  the 
source  of  blood  may  be  from  within  the  cavity,  either 
from  division  of  some  large  vessel  or  from  injured  vis- 
cera ;  or  may  be  caused  by  the  division  of  the  epigas- 
tric artery  while  coursing  in  the  abdominal  walls. 
Should  the  orifice  made  by  the  ball  lie  directly  over  the 
course  of  this  vessel,  and  external  hemorrhage  be  ex- 
cessive, t lie  wound  should  be  dilated,  the  bleeding  orU 
■light  for,  and,  when  found,  ligated.  When,  from 
the  former  source,  but  little  can  be  done,  venesection 
to  syncope  might  check  the  flow,  and  the  formation  of 
a  clot  may  plug  up  the  injured  vessel.  Some  sur- 
gOons,  knowing  tin'  desperate  condition  brought  on 
by  internal  hemorrhage,  recommend  dilating  the 
wound;  and,  should  it  be  found  that  hemorrhage 
conies  from  one  of  the  mesenteric  vessels,  the  artery 
should  be  ligated.    The  position  of  the  external  wound 


348  PERFORATING    ABDOMINAL    WOUNDS. 

will  assist  us  in  forming  a  diagnosis  us  to  the  proba- 
ble source  of  the  hemorrhage.  Cases  of  recovery  are 
recorded  where  the  wound  was  diluted,  and  the  bleed- 
ing vessel  in  the  omentum  sough  1  for  and  secured. 

Where  some  of  the  large  viscera  or  blood-vessels 
are  injured  in  perforating  abdominal  wounds,  the 
Symptoms  are  mnoh  more  marked  than  in  intestinal 
wounds;  hemorrhage  at  once  takes  place,  to  a  serious 
and  often  fatal  extent.  Such  wounded  are  often 
found  dead  upon  the  battle-field;  or,  should  they  be 
alive,  they  are  pale  and  cold,  with  anxious  counte- 
nances, and  intense  longing  for  water.  This  insatiable 
thirst  is  not  peculiar  to  visceral  wound  or  to  nervous 
.shock,  but  is  an  indication  of  serious  hemorrhage. 
Should  the  wound  be  extensive,  they  never  rally  from 
this  collapse.  In  other  cases-the  shock  may  permit  the 
clogging  of  injured  blood- vessel 8,  and  may  stop  inter- 
nal bleeding.  Should  life  be  prolonged  until  reaction 
takes  place,  the  violent  inflammation  which  is  lit  up, 
either  from  direct  injury  to  the  peritoneum  or  from 
the  quantity  of  blood  in  the  cavity,  usually  carries  nil' 
the  patient  after  a  period  of  intense  suffering. 

On  account  of  the  hemorrhage  and  subsequent  in- 
flammation which  accompany  these  injuries,  all  gun- 
shot  wounds  of  the  larger  abdominal  viscera  are  con- 
sidered nearly  necessarily  mortal,  and  exceptional 
cures  are  rare.  Punctured  wounds  of  the  liver,  stom- 
ach, or  kidneys  are  often  saved,  and  even  gunshot 
wounds  of  these  viscera  are  at  times  recovered  from. 
AVhen  the  external  orifice  is  small,  the  position  and 
direction  of  the  wound  will  lead  us  to  suspect  the 
special  injury,  and,  in  connection  with  persistent  vom- 
iting, the  ejection  of  blood  by  tho  mouth,  by  stool,  or 
with  the  urine ;  the  escape   of  special  secretions,  as 


WOUNDS    OF    STOMACH."  340 

bile,  urine,  or  feces  by  the  wound;  and  the  peculiar 
pain  or  sensations  experienced  by  the  patient — will  be 
our  chief  indications  in  locating  the  injury. 

In  gunshot  wounds  of  the  stomach  the  contents  es- 
cape externally,  and  also  into  the  peritoneal  cavity, 
where,  as  extraneous  substances,  they  light  up  gen- 
eral and,  usually,  fatal  peritonitis.  As  soldiers  most 
frequently  go  into  battle  without  previously  having 
had  a  meal,  the  flaccid  condition  of  the  stomach,  with- 
out contents  to  escape  from  this  organ,  is  a  great 
safeguard  in  case  of  wounds,  and  hence  perforating 
wounds  of  this  viscus  more  frequently  recover  under 
t  hese  circumstances  than  when  gunshot  injuries  are 
received  under  other  conditions.  The  location  of  the 
wound  is  often,  in  the  army,  the  only  basis  for  diagno- 
sis, as  the  escape  of  contents  and  vomiting  of  blood 
are  not  constant  sjnnptoms,  and  shock,  which  is  usual- 
ly present,  is  common  to  all  wounds  of  the  abdominal 
viscera.  When  the  patient  survives  the  reactionary 
state  from  the  effects  of  gunshot  wounds  of  the  liver, 
bile  continues  to  flow  from  the  wound,  often  in  largo 
quantity,  the  patient  gradually  becoming  emaciated. 
He  is  rendered  more  feeble  by  diarrhoea,  induced  from 
the  absence  of  the  biliary  secretion  in  the  intestines, 
where  its  antiseptic  properties  are  required  to  prevent 
decomposition  of  thcinjesta,  and  continued  irritation. 
In  kidney  mounds  the  most  fatal  complication  de- 
pends upon  the  infiltration  of  urine  in  the  contiguous 
cellular  tissue,  creating  extensive  sloughs,  poisoning 
the  blood,  and  usually  rapidly  destroying  life.  Great 
pain  in  the  lumbar  region,  frequent  micturition,  with 
bloody  urine,  retraction  of  the  testicle,  nausea,  vomit- 
ing, indicate  the  injury.  These  cases  usually  do  bad- 
ly, and,  in  the  experience  of  many  army  surgeons, 
arc  always  fatal.      \Y<    now   and  then   hear  of  wounds 


3o0  '     KIDNEY    WOUNDS. 

of  the  kidneys  recovering,  but  their  rarity  only  bring 
the  fatal  character  <>(  the  lesion  more  prominently 
forward.  It'  the  exit  for  urine  from  the  wound  be 
free,  then  infiltration  may  no1  occur,  and  in  these 
pare  instances  the  siee  and  location  of  the  wound  may 
be  instrumental  in  effecting  a  cure.  This  is  more 
especially  the  case  where  the  injury  is  an  oblique  one, 
which  has  not  implicated  the  abdomen. 

The  treatment  of  these  serious  wounds,  which,  on 
the  whole,  is  so  unsatisfactory,  is  similar  to  that  re- 
quired for  perforating  wounds  of  the  chest,  with  in- 
jury to  the  lungs.  Opium  internally,  and  cold  locally, 
with  absolute  diet,  should  become  the  basis  of  treat- 
ment.    A  little  water  or  small  jiieees  of  ice  is  all  that 

the  patient  requires  during  the  first  two  or  three  days. 

In  injuries  to  the  bladder,  bloody  urine,  or  rather  the 
passage  of  clots  as  well  as  pure  blood  through  the 
penis,  is  the  diagnostic  sign.  Should  urine  escape 
from  the  wound,  it  is  equally  pathognomonic.  In  ad- 
dition to  the  course  -already  laid  down  for  internal 
abdominal  injuries,  the  introduction,  by  the  penis,  of 
a  large  gum  catheter  into  the  bladder,  through  which 
urine  is  allowed  to  drain  away  as  fast  as  it  is  secret- 
ed, will  assist  in  preventing  urinous  infiltration,  which 
is  one  of  the  most  fatal  complications  connected  with 
a  wounded  bladder.  The  catheter  should  be  intro- 
duced as  soon  as  possible  after  the  reception  of  the 
wound,  and  should  be  worn  continuously  for  four  or 
five  days,  until  adhesive  inflammation  has  closed  the 
torn    cellular   tissue,    and   shut     up   the    avenues    into 

which   the    urine    would    have   escaped.     Should  the 
injury  be    at    the   neck   of    the   bladder,   the    catheter 
will  also  be  required  when   the  sloughs  are  separat-* 
ing,   as   swelling    of    the    parts   often   obstructs   the 
ready  flow  of  urine.     The  gum  catheter  may  even  be 


"if"  / 

WOUNDS   OF    BLADDER.  351 

kept  in  from  the  commencement  of  the  treatment  un- 
til the  wound  is  well  advanced  in  healing,  unless  it 
excites  much  irritation,*when  it  may  be  temporarily 
withdrawn.  This  precaution  will  prevent  many  cases 
of  urinous  infiltration,  and  save  many  lives. 

Although  this  is  clearly  the  course  to  be  pursued, 
it  is  often  impossible  of  attainment,  as,  even  in  the 
hands  of  a  skilful  manipulator,  the  instrument  can  not 
be  introduced  when  the  neck  of  the  bladder,  or  the 
prostatic  part  of  the  urethra,  has  been  divided.  Jf 
the  catheter  can  not  be  passed  into  the  bladder  a  free 
incision  should  be  made  through  the  perineum  for 
the  evacuation  of  urine  and  the  discharges  from  the 
wound. 

The  following  case  is  pertinent  to  the  subject,  as  it 
clearly  demanded  a  perineal  incision;  the  surgeon 
having  failed  to  make  it,  nature  in  time  eifected  it, 
but  too  late  for  the  salvation  of  the  patient. 

Private  T.  Young,  Company  (x,  7th  New  Hamp- 
shire regiment,  was  shot,  on  the  18th  of  July,  at  the 
assault  upon  Battery  Wagner,  Morris  island.  The 
ball  entered  the  outer  and  posterior  side  of  the  left 
hip,  about  two  inches  below  the  great  trochanter. 
Its  range  was  slightly  upward.  Having  passed  under 
the  skin  of  the  perineum,  cutting  the  urethra  in  the 
vicinity  of  its  membraneous  portion,  the  ball  was  de- 
flected downward  from  its  straight  course,  making  its 
exit  on  the  outer  and  posterior  side  of  the  right  thigh, 
four  inches  below  the  great  trochanter.  When 
brought  into  hospital,  the  day  after  the  assault,  at- 
tempts were  in  vain  made  by  the  surgeon  in  attend- 
ance to  introduce  a  catheter.  Urine  flowed  from  both 
wounds  in  the  thighs,  at  first  involuntarily.  After 
a  few  days  the  patient  gained  control  of  his  bladder, 
but  could  not  direct  the  stream  of  urine,  which  still 


352  W01  ND8   01    BLADDER. 


™ 


l  out  of  ill"  thigh  wounds  whenever  he  mictu- 
rated.  An  abscess  oventually  formed  in  the  perineum, 
which,  when  opened  three  weeks  after  the  injury,  also 
gave  vent  to  urine.  The  patient  died  with  extreme 
emaciation* 

One  of  the  chief  points  of  interest  in  this  case  is 
the  long  track  through  which  the  urine  found  its  way 
immediately  after  the  injury,  and  by  which  it  con- 
tinued t<>  escape.  None  was  at  any  time  passed 
through  the  penis,  although  the  patient  bad  a  perfect 
contro]  over  the  bladder. 

Fortunate  it  is  for  men  going  into  battle  thai  the 
excitement  under  which  the  troops -are  at  thai  lime 
Laboring  causes  a  continual  dropping  from  the  ranks 

to  urinate.  BO  that   rarely  does  a  soldier  go  into  battle 

with  his  bladder  full.  In  this  physiological  fact  lies 
the  safety  of  many  a  man,  as  the  contracted  bladder, 
concealed  behind  the  pubis,  in  the  cavity  of  the  pelvis, 
often  escapes  injury  from  the  passage  of  a  ball,  which, 
were  the  organ  distended,  would  assuredly  traverse  it. 
Our  hospital  reports  give  several  eases  of  vesical  in- 
jury successfully  treated.  Among  these  is  one  of 
special  interest,  in  which  the  ball,  in  traversing  the 
pelvic   region   antero-posteriorly,   transfixed    bladder 

and  rectum,  anterior  abdominal  wall,  and  saeruin.  lis 
extent  was  reeo^ni/.ed  by  the  escape  of  urine  ante- 
riorly, and  urine  with  I'ecal  matter  through  the  sacral 
orifice,  as  well  as  urine  running  off  h\    the  rectum.      In 

time  these  orifices  closed,  and  the  patient  was  dis- 
charged cured. 

On  May  ."».  l^t'..;.  I  removed  an  encysted  calculus 
from  the  bladder  of  Private  R.  S.  Moore,  Company  K, 

Palmetto  Sharp-shooters,  who  was   shot  at  the    Battle 

of  Prazer's  Farm,  June  29,  1862.  'The  ball  passed 
obliquely,  entering  at  the  right  Bide  of  the  abdomen, 


WOUNDS    OP    BLADDER.  353 

on  a  level  with  the  crest  of  the  pubic  hone,  crushing 
its  outer  surface,  then  traversing  the  bladder,  and  es- 
caping through  the  left  buttock,  between  the  tuberosity 
of  the  ischium  and  base  of  coccj'-x.  For  several  days 
after  the  injury  the  bladder  emptied  itself  through 
both  of  these  orifices,  no  urine  escaping  by  the  penis. 
After  discharging  urine  for  several  weeks,  the  wound 
in  the  buttock  closed,  the  abdominal  wound  continu- 
ing to  discharge  urine  up  to  the  day  of  operation  for 
lithotomy — nearly  eleven  months.  During  this  period 
he  has  passed  by  the  penis  pieces  of  bone  as  well  as 
fragments  of  calculus.  For  four  months  he  had  been 
aware  of  the  presence  of  a  stone,  which  he  felt  rolling 
in  his  bladder.  He  had  been  confined  to  his  bed  for  ten 
months,  and  was  exceedingly  emaciated,  with  hectic, 
when  he  presented  himself  for  operation.  So  direct 
was  the  communication  of  the  anterior  fistula  with  the 
bladder;  that,  when  this  viscus  was  injected,  prior  to 
the  operation,  the  water  escaped  so  rapidly  from  the 
fistula  as  to  empty  the  bladder  before  it  could  be 
opened.  A  round  stone  an  inch  in  diameter  was  found 
encysted  over  the  pubic  region,  and  was  removed  with 
much  difficulty.  The  case  recovered  verj^  rapidly. 
The  abdominal  opening  closed  up  at  once,  no  urine 
escaping  from  it  after  the  operation.  The  nucleus  of 
the  calculus  was  paste-like,  with  no  trace  of  a  foreign 
body  which  I  expected  to  find.  Among  the  many 
points  of  interest  which  the  case  possesses,  is  the  one  of 
the  orifice  of  exit  healing  tir>t.  although  urine  was 
discharged  through  it  as  the  most  dependent  orifice. 

Injur}/  to  the  large  intestines,  when  not  involving  the 
peritoneal  cavity,  arc  not  so  serious  as  perforations  of 
the  small.  As  the  large  bowel  is  bound  down  in  the 
greater  pari  of  it-  course,  extravasations  of  their  con- 
tern-  do  not  necessarily  take  place  into  the  i  bdominal 
Dd 


354  RUPTURE    OV    AHl.cMINAL    VI8CERA. 

cavity  j  and  although  fecal  matter  escapes  externally 
from  the  wound,  and  high  inflammation,  with  profuse 
suppuration,  usually  follows,  many  of  the  wounded 
eventually  do  well. 

Cases  not  unusually  occur  on  the  battle-field  in 
which  the  abdominal  contents  might  be  severely  crush- 
ed without  apparent  external  injury.  It  is  the  tough- 
ness and  elasticity  of  the  skin  which  gives  rise  to  the 
exploded  theory  of  the  wind  of  a  ball  destroying  life  ; 
and  such  cases  as  those  we  are  now  considering  were 
formerly  brought  forward  as  instances  of  the  fatal 
effects  of  the  vacuum  following  the  wake  of  a  cannon- 
ball. 

Observation  has  shown  that  a  knapsack  might  be 
torn  from  the  back,  a  hat  struck  from  the  head,  an 
epaulet  from  the  shoulder,  or  a  pipe  from  the  mouth, 
without  leaving  a  trace  of  injury;  while,  on  the  other 
hand,  viscera  might  be  reduced  to  a  jelly,  or  bones 
crushed,  without  a  visible  bruising  of  the  skin.  It  is 
tho  ball  itself,  and  not  the  wind,  which  produces  these 
disorganizations.  From  the  blow.of  a  spent  cannon- 
ball  or  fragment  of  a  shell  the  liver  might  be  lacerated, 
intestines  torn,  blood-vessels  opened,  spleen  fissured,  or 
kidney  ruptured,  without  an  external  wound.  Severe 
shock  and  collapse  mark  the  extent  of  injury  received  ; 
and  should  the  patient  rally  from  this  condition,  which 
is  rare,  violent  inflammation  will  soon  destroy  life. 
Although  we  follow  vigorously  the  treatment  laid  down 
above,  we  very  seldom  have  tho  satisfaction  of  saving 
a  patient. 

Sergeant  E.  L.  Davis,  Company  < ',  7th  battalion  S. 
C.  V.,  was  injured,  on  the  10th  of  July,  during  the  bom- 
bardment of  Battery  Wagner,  by  the  explosion  of  a 
shell.  Two  days  afterward,  when  he  entei-ed  the  gen- 
eral hospital,  he  complained  of  pain  in  the  left  lumbar 


EFFECT    OF    SPENT    BALLS.  o55 

region,  where  he  had  been  struck.  There  was  no 
eschimosis  present,  although  there  existed  some  tume- 
faction— not,  however,  sufficient  to  excite  any  appre- 
hension. There  was  slight  abrasion  about  his  face  and 
right  side.  Six  days  after  the  injury,  he  having  suf- 
fered much  with  pain,  fluctuation  was  detected  in  the 
lumbar  region.  A  puncture  was  made,  which  dis- 
charged a  large  quantity  of  pus,  and,  with  it,  fecal 
matter.  Some  of  this  escaping  into  the  cellular  tissue 
of  the  loin  and  buttock  induced  a  phlegmonous  con- 
dition, with  rapid  sloughing  of  cellular  tissue.  Al- 
though free  incisions  were  made,  the  sloughing  could 
not  be  checked.  It  extended  in  every  direction,  until 
one  vast  sloughing  cavity  occupied  half  the  trunk,  from 
the  ribs  to  the  trochanter,  and  from  the  vertebral  col- 
umn to  the  pubis.  An  autopsy  revealed  a  double  rup- 
ture in  the  descending  colon,  with  openings  parallel  to 
the  circular  fibres,  which  had  permitted  the  free  escape 
of  fecal  matter  into  the  cellular  tissue,  between  the 
bowel  and  quadratus  lumborum  muscle.  Collecting 
in  quantity,  it  had  separated  and  disorganized  the  tis- 
sues as  low  as  Poussart's  ligament,  forming  a  large  sac 
distinct  from  the  peritoneal  cavity,  and  separated  from 
it  only  by  the  peritoneum.  In  this  the  iliac  artery  was 
lyitig  bare.  Had  the  feces  not  escaped  in  the  loin  it 
would  have  dissected  to  the  groin,  as  the  fecal  cavity 
was  hounded  below  by  Poussart's  ligament. 

The  amount  of  destruction  effected  by  a  spent  ball 
is  often  surprising.  The  uninitiated  on  tin-  battle-field 
will  attempt  to  Stop,  with  the  foot,  a  cannon-ball  roll- 
ing on  the  ground,  and  which  is  just  about  exhausting 
its  force,  perhaps  with  only  momentum  sufficient  to 
Carry  it  one  or  two  feel  further,  yet  it  crushes  the 
limb  pu1  out  to  oppose  it.  Baudens.in  warning  persons 
to  avoirl   cannon-balls,  however  slowly   they   may   he 


BALLS    IN    PBLVIO   OAYD  I. 

rolling,  mentions  the  case  of  m  grenadier  of  the  guard, 
Bleeping  on  bis  Bide  on  the  gronnd,  who  was  instantly 
killed  by  :»  spenl  cannon-ball,  the  blow  from  which 
luxated  the  vertebral  column.  The  ball  came  with  so 
little  momentum  that  it  rolled  itself  up  in  the  hood  of 
the  soldier's  overcoat,  where  it  was  found.  Lt  was  just 
about  to  slop  when  it  struck.  Oneor  two  feel  further, 
an<l  its  entire  force  would  have  been  exhausted. 

Balls  nearly  spent,  in  perforating  the  pelvic  cavity, 
expend  all  of  their  force  in  passing  through  the  bones, 
and  then  remain  embedded  in  the  cellular  tissue.  As 
such  wounds  do  not  readily  heal,  on  account  of  spicules 
of  bone  keeping  up  a  discharge,  a  probe  can  he  passed 

through    the  orifice  in  the  hone  to  the   hall    beyond   it. 

In  the  ease  of  Private  B.  •'  Mm  thews,  of  the  26th  Ala- 
bama regiment,  a  youth  of  fourteen  years,  who,  when 
returning  from  a  tilth  charge  against  :i  Yankee  bat- 
tery during  one  of  the  Battles  of  Richmond,  was  shot 
in  the  hack;  the  hall  entered  through  the  sacrum  an 

inch  from  its  BpinOUS  processes,  and  one  inch  below  the 
level  of  the  crest  of  the  ilium.      Eight  months  after  the 

reception  of  the  wound  he  applied  to  me  for  relief,  as 

he  had  a  constant  discharge  of  pus  from  both  the 
wound  in  the  hack  and  a  fistulous  passage  in  the  left 
groin.      Upon  examination  with  a  probe,  which  passed 

in  four  inches,  traversing  the  sacrum,  the  foreign  body 

was  detected,  the  bulb  of  the  prohe  entering  the  cup 
of  the-  minie  hall.  Uy  using  a  gouge,  the  orifice 
through  the  sacrum  was  enlarged  sufficiently  to  allow 
the  hall  being  drawn  from  the  pelvic  cavity.     The  case 

recovered. 


CHAPTEE    XII. 

Injuries  of  the  Extremities — Compound  Fractures — Difference 
of  treatment  in  tiie  Utter  and  Lower  Limbs — Importance  of  an 
early  Examination  and  adoption  of  a  Course  of  Treatment 
within  twenty-four  hours  after  the  receipt  of  Accident — 
Compound  Fractures  OF  the  Arm  from  Shot  Wounds,  when  not 
implicating  Joints,  do  not  require  Amputation;  should  the 
Blood-vessels  and  Nerves  be  crushed  with  the  Bone,  then 
Amputation  necessary — When  Gunshot  Fractures  implicate 
Joints,  Resection  or  Amputation  is  the  best  means  of  saving 
Life — -How  Resections  are  to  be  performed — Special  Resec- 
tions of  Shoulder,  Elbow,  Wrist — Resections  and  Amputations 
of  the  inferior  extremity — Primary  and  Consecutive  Amputa- 
tion— When,  and  under  what  circumstances,  Amputations 
should  be  performed — modes  of  operating  and  of  dressing 

STUMPS. 

As  the  major  portion  of  the  injuries  of  the  extremi- 
ties are  merely  flesh  wounds,  these  will  not  require  to 
be  now  noticed,  but  the  effects  of  such  wounds  in  im- 
pairing the  uses  of  a  limb  will  be  hereafter  considered. 
Those  which  we  will  now  discuss  are  such  as  involve 
the  bones,  joints,  or  important  vessels,  and  which  may 
call  for  special  treatment.  It  is  in  this  department 
that  conservative  SUrgerj  lias  made  the  greatest  ad- 
vances, and  has  accomplished  so  much  in  diminishing 
mortality  and  mutilation.  Not  that  amputations  will 
ever  be  abolished,  tor  many  lives  can  be  saved  in  no 

Other  way  than  by  the  sacrifice  Of  limbs  ;  but  conserva- 
tive BUrgery  lias  shown  that  the  constant  flourish  <>f 
the  amputating  knife  is  not  the  way  to  obtain  the 
greatest  number  of  BUrgical  Victories  in  tines  of  war. 
Amputations  must,  however,   ever   remain    a  surgical 


358  0UN8H0T    rRACTUB*. 

jsity  ;  :ui<l  be  who  removes  crashed  limbs  with 
the  greatest  skill,  and  saves  the  patient*by  successful 
after-treatment,  will  ever  deserve  the  high  position 
which  humanity  :i!i<l  philanthropy  will  bestow  upon 
him. 

In  gunshot  wounds  of  the  extremities  we  find  a 
mnch  greater  vitality  and  resistance  to  injuries  in  the 
upper  than  in  the  lower  limbs,  which  would  modify  the 
treatment  of  similar  injuries  located  in  these  two  por- 
tions of  the  body.  This  depends  upon  the  greater 
vascularity  and  freer  anastomosis  in  the  arm  than  in 
the  leic-  I"  the  more  liberal  supply  of  blood-vessels 
and  nerves  we  find  the  source  of  safety  which  enables 

US   l"   sivr   an    arm,  when,  for  a   similar  injury,  a    leg 

would  be  generally  condemned. 

The  most  common  accidents  to  the  extremities 
whioh  give  Burgeons  the  greatest  annoyance,  and  re- 
quire the  most  careful  diagnosis,  prognosis,  and  treat- 
ment, are  compound  fractures.  These  have  always 
made  a  numerous  and  important  class  in  military  sur- 
gery,  but  have  become  doubly  so  in  modern  warfare, 
from  the  substitution  of  conical  shot  for  the  round 
musket-ball.     This  projectile  Beldom  impinges  upon  a 

hoic    without    leaving   frightful    traces  of  devastation. 

Such  a  conioal  ball  rarely  remains  embedded,  but, 
acting  on  the  principle  of  6  wedgo,  splits  and  commi- 
nutes the  bone,  driving  the  loose  spicules  in  every  di- 
rect ion  before  it . 

When  a  hone  is  crushed  by  a  ball,  the  patient  i-  con- 
veyed very  carefully  to  the  field  infirmary;  or,  if  it 
can  be  done  without  delay,  to  the  general  hospital, 

where   the    treatment    commences.      <  >n    the    field    the 

ambulance  surgeon  can  do  nothing  but  administer  a 
dose  of  morphine,  ami    secure    the  limb  t<»  a  rough 

splint,   to   facilitate    transportation.      for  a    fractured 


PROGRESS    OF    GUNSHOT    FRACTURE.  359 

clavicle,  scapula,  or  humerus,  the  arm  is  bandaged  to 
the  chest,  which,  on  the  battle-field,  answers  the  pur- 
pose of  a  temporary  splint;  for  a  crushing  of  the 
forearm  or  hand,  the  arm  PS  laid  upon  a  board  splint, 
and  slung  from  the  neck.  If  the  splint  is  not  at  hand, 
the  sling  made  of  a  handkerchief  must  answer  until 
the  wounded  man  can  be  better  attended  to — it  being 
understood  that  a  wet  or  greased  cloth  is  always  put 
over  the  wound  for  its  protection  during  the  transpor- 
tation. 

When  he  arrives  at  the  hospital  the  limb  is  care- 
fully examined.  The  external  wound  may  give  no 
indication  of  the  extent  of  internal  injury.  When 
the  finger  is  introduced  and  the  wound  carefully 
explored,  the  degree  of  crushing  will  be  ascertained, 
and  the  question  at  once  proposes  itself:  what  course 
shall  we  pursue?  Shall  we  attempt  to  save  the  limb ; 
or  does  its  condition,  with  the  want  of  proper  facili- 
ties for  its  successful  treatment,  necessitate  its  con- 
demnation? If  we  have  had  experience  in  the  care 
of  gunshot  fractures,  we  should  anticipate  the  dan- 
gers, and,  with  Sir  Charles  Bell,  contemplate  what 
will  be  the  condition  of  the  parts  in  thirty-six  hours, 
in  twelve  days,  or  in  three  months.  In  thirty-six 
hours  the  inflammation,  pain,  and  tension  of  the  whole 
limb,  the  anxious  countenance,  the  brilliant  eye,  the 
BleepldBfl  an  1  restless  condition,  declare  the  impression 
the  injury  is  making  on  the  limb  and  on  the  constitu- 
tional powers.  In  twelve  days  ihe  affected  limb  is  swol- 
len t<>  sometimes  half  the  size   of  the  body  ;   a  violent 

phlegmonous  inflammation  may  pervade  the  whole; 

seronB  effusion  lias  taken  place  in  the  limb,  and  ab- 

ea  are  forming  in  the  great  beds  of  cellular  texture 

through  which  the  hall  has-  passed;  from  the  wound 
pus  is  escaping  in  large  quantities,  impoverishing  the 


riU.MAKV   AMPUTATION    PRKKBABLK. 

blood,  and  rendering  the  Bystem  irritable.  In  throe 
months,  if  the  patienl  has  labored  through  tins  length- 
ened agony,  the  bones  are  carious;  the  abscesses  are 
interminable  Binnses,  from*which  are  kept  up  a  con- 
tinued discharge  j  the  patienl  is  pale  and  emaciated, 
with  hectic  flushes  and  diarrhoea,  and  the  constitu- 
t i •  •  1 1 :i  1  strength  ebbs  to  the  lowesl  degree.  All  these 
conditions  must  be  rapidly  considered,  ami  with  them 
the  more  immediate  dangers  "f  mortification,  ami  the 
remote  dangers  <>f  erysipelas,  pyemia,  and  hectic,  ami 
the  questionable  utility  of  the  limb,  when,  after  sever- 
al months  of  continued  trials,  the  wound  has  been 
healed,  hut  the  limb  remains  weak,  shrunken,  stiff) 

painful,  and   nearly  useless. 

Our  conclusions  must  be  made  and  acted  upon 
within  twenty-four  hours,  or  before  reaction  sets  in, 
while  tlu-  patient  has  bis  sensibilities  depressed  by  the 
Bhock.     Success  of  treatment   depends  upon  prompt 

action — the  delay  of  a  few  days  has  destroyed  thou- 
sands of  wounded.      Should   amputation   he   required, 

there  is  no  period  in  the  progress  of  the  case  so  favor- 
able for  the  performance  of  this  operation  as  the  first 
four-and-l  wenty  hours.    Should  an  injudicious  at  temp! 

he  made  to  save  the  limit,  until  suppurative  act  ion  has 

been  well  established  an  amputation  can  not  he  resort- 
ed to  with  a-  good  prospects  of  success  as  prior  to  the 

development  of  the  inflammatory  stage.  Should  ery- 
sipelas  attack  the  wound,  an  amputation  is  impracti- 
cable; ami  when  gangrene  has  supervened, during  the 

Stage  "I'  reactionary  excitement,  we  are  driven  t<>  an 
operation  under  the   most    unfavorable  circumstance-. 


rniMARY    AMPUTATIONS    rilEFKRAKLE. 


361 


Consolidated  Tabic  of  Amputations,  from   June  1,  1862,  to  February  1, 
1864,  collated  from  reports  in  the  Surgeon-General's  office. 


Primary. 


Secondary. 


Thigh 

Log 

Arm 

Forearm 

Shoulder-joint. 
Elbow-joint . . . 
Wrist-joint. . . . 

Hip-joint 

Knee-joint 
Ankle-joint  . . . 
Tar8al-joint . . . 


Total 


345 

213 

132 

1 
38 

162 

43 

119 

314 

219 

95 

30 

150 

76 

74 

294 

252 

42 

14 

140 

87 

53 

69 

61 

8 

12 

4ft 

3ft 

10 

79 

54 

25 

31 

28 

B 

20 

4 

3 

1 

25 

8 

2 

1 

7 

ft 

2 

28 

. .  • 

3 

1 

2 

66 

• . . 

• . . 

5 

2 

3 

60 

6 

6 

6 

4 

2 

33 

4 

16 

13 

3 

19 

27 

8 
546 

262 

1 

284 

1,149 

827 

31ft 

49 

37 

■22 

n 


100 
12 


The  report  of  a  much  larger  number  of  amputa- 
tions have  been  received  at  the  Surgeon-General's 
office,  but  as  the  results  of  treatment  in  many  cases 
have  not  been  given,  these  doubtful  successes  have 
been  purposely  omitted  from  this  table. 

There  are  numerous  compound  fractures  upon  which 
judgment  can  be  immediately  passed:  with  some,  there 
is  every  probability  that  the  limb  can  be  saved;  while, 
there  are  others  in  which  the  limb  is  condemned  at  a 
glance — our  prognosis  being  based  upon  the  following 
circumstances:  As  the  upper  extremity  can  sustain 
a  much  more  serious  injury  than  the  lower,  we  may 
lay  it  down  as  a  rule  that  a  compound  fracture  of  any 
of  the  long  bones  of  the  arm,  when  not  complicated 
With  excessive  crushing  of  tho  soft  parts,  or  injury  to 
blood-vessels  and  nerves,  can  and  should  be  saved. 
An  arm  i>  rarely  t<>  l>c  amputated  for  recent  gunshot 
injuries,  except  from  tho  effects  of' balls  breaking  up 
Be 


862  TREATMENT   OF   COMPOUND    FRACTURES. 

extensively  the  shaft,  with  long  tissuivs  extending  into 

joints,  or  where  cannon-shot  or  fragment's  of  shell,  he- 
sides  crashing  the  hones,  makes  frightful  lacerations 
of  the  soft  tissues,  tearing  away  muscles,  nerves,  and 
blood-vessels,  and  even  at  times  carrying  off  the  limb— 
the  Burgeon's  services  being  required  only  to  give  a 
better  form  to  the  stum]). 

For  a  gunshot  wound  from  a  musket  or  minie  ball, 
which  has  fractured  the  hones  of  the  arm  without 
implicating  a  joint,  the  following  is  the  course  to  be 
pursued:  At  the  field  infirmary  the  wound  is  care- 
fully probed  with  the  tingcr,  and  its  spiculated  condi- 
tion noted.  All  loose  fragments  are  to  be  remov 
this  first  examination, before  reaction  ensues,  for  it  will 
be  very  injurious  to  the  wound,  as  well  a-  excessively 

painful   to  the  soldier,  to  continue  such    examinations 

from  day  to  day.  The  first  examination  should  al- 
ways he  effectual.  The  patient  is  then  suffering  from 
shock,  with  sensibility  temporarily  blunted,  and  is, 

therefore,  in  the  host  condition  to  be  operated  upon. 
To  render  this  first  examination  complete,  should  the 
Shock  have  passed  oft'  and  the  patient  complain  of 
much  pain,  it  would  be  better  to  give  him  largo  doses 
of  opium,  or  administer  chloroform,  rather  than  desist 
from  this  important  portion  of  the  treatment.  Make 
a  thorough  exploration  with  the  finger  passed  into 
both  orifices,  and  should  the  bone  he  found  much 
crushed,  and  the  orifice^  made  bythe  ball  not  sufii- 
ciently  large  to  permit  of  their  easy  extraction,  dilate 
the  opening  and  remove  all  detached  fragments. 
Should  we  omit  to  bring  away  all  spicuhe.  the  further 
removal  should  not  he  attempted  during  the  stage  of 
excitement  and  febrile  reaction,  which  will  come  on 
after  twenty-four  hours,  and  which  will  run  its  course 
in  six  or  eight  days.      When   this  BUbsides,  then,  and 


REMOVAL   OF    FRAGMENTS.  .'W3 

not  before,  we  make  the  second  examination,  and,  by 
the  use  of  instruments,  remove  any  loose  fragment 
which  we  may  now  detect.  Wo  will  simply  mention, 
in  this  connection,  that  as  there  is  not  the  slightest 
probability,  or  even  possibility,  of  the  wound  closing 
by  the  first  intention,  the  insertion  of  tents  and  pieces 
of  lint  is  a  relic  of  barbarous  surgery,  which  being 
useless,  injurious,  and  very  painful,  can  not  be  too 
severely  condemned. 

Modern  surgery  recommends  that  all  spiculae, 
whether  detached  or  not,  should  be  removed,  but  this 
practice,  unfortunately,  is  not  carried  out  b}-  surgeons 
generally;  and,  as  the  result  of  this  negligence,  our 
country  and  hospitals  arc  filled  with  cases  of  necrosis 
of  one  and  two  years'  standing — men  who  add  mate- 
rially to  the  numbers  and  expense  of  an  army,  without 
in  any  way  increasing  its  efficiency.  .Experience  and 
observation  has,  in  a  few  instances,  shown  that, 
although  large  fragments  ma}*  be  detached  from  the 
shaft  of  the  bone,  they  may  still  be  adherent  to  the 
periosteum,  which  may  effect  a  reunion  and  consolida- 
tion.. On  the  other  hand,  experience  and  observation 
continually  show  that,  from  the  force  with  which  coni- 
cal shot  strike  a  bone,  the  spicules,  which  may  be  very 
numerous,  are  driven  in  every  direction,  but  generally 
toward  the  opening  <>f  escape  of  the  ball.  At  other 
times  the  bone  is  broken  in  larger  pieces  and  is  split, 
fissures  extending  upon  the  Bhafl  for  some  distance, 
even  perhaps  to  t  he  adjacenl  articulation.  These  sharp 
splinters  can  not  but  produce  excessive  irritation  in  the 
soft  parts,  and  may,  by  transfixing  vessels,  pricking 
nerves,  or  irritating  muscles,  induce  hemorrhage,  mor- 
tification, or  tetanus.  Or  inflammation  of  the  lining 
membrane  and  periostial  envelope,  with  profuse  dis- 
charge,   may    entail    rapid    prostration    and    intense 


364  KKMovAL   OF    FRAGMKNT8. 

suffering.  No  surgeon  doubts  the  propriety  of  re- 
moving all  such  fragments  on  tho  spot,  or  at  the 
earliest  possible  moment.  As  the  opening  of  exit, 
around  which  the  Larger  number  of  tin*  fragments  are 
found,  may  be  too  oontraoted  to  admit  of  a  thorough 
exploration  of  the  wound,  it  will  not  increase  the 
dangers,  but,  on  the  contrary,  materially  diminish 
the  risks  of  after-trouble,  if  the  wound  of  exit,  in  coin- 
pound  fractures  with  crushing  of  the  bone,  be  dilated, 
so  as  to  facilitate  the  detection  and  removal  of  every 
spiculse.  In  enlarging  this  orifice,  injury  to  the  im- 
portant blood-vessels  and  nerves  will,  of  course,  be 
avoided  by  incising  parallel  to  the  axis  of  the  limb. 

<)n  the  subject  of  removing  'ill  fragments,  whether 
detached  or  not,  there  appears  to  be  no  longer  a  diver- 
sity of  opinion.  The  older  surgeons,  who  base  their 
treatment  on  the  effects  of  round  balls,  believe  that 
often  the  connection  of  the  fragments  to  the  soft  parts 
and  to  tho  periosteum  will  guarantee  a  consolidation 
of  the  fragments.  The  round  hall  simply  breaks  the 
bone  without  usually  scattering  the  fragments,  and. 
therefore,  their  relations  to  the  surrounding  tissues 
will  not  be  so  materially  changed.  But,  not  withstand- 
ing this  impression,  which  mayor  may  not  be  correot, 
what  does  actual  experience  prove,  when  reduced  to 
facts  ? 

Take  tho  experience  given  by  the  inmates  of  the 
Hotel  des  Invali.des,  as  recordod  by  M.  I  In  tin,  tho  sur- 
geon of  the  institution.  lie  states  that  those  spicuhe 
which  had  been  attachod  to  the  soft  parts,  and  which 
were  allowed  to  remain  in  the  hope  of  reunion, 
although  they  may  not  give  trouble  at  the  moment, 
invariably  end  by  becoming  sequestra,  and,  after  a  long 
period  of  pain  and  suppuration,  demand  removal.  He 
reports  several   hundred   cases   in  which   the  retained 


REMOVAL   OP    FRAGMENTS.  ,'5t)5 

fragments,  sooner  or  latei',  set  up  an  elimi native  action, 
which  is  always  painful,  often  dangerous,  and  at  times 
fatal.  M.  Ilutin  refers  chiefly  to  the  effects  of  round 
or  musket  balls.  Baudens  gives,  as  his  Crimean  ex- 
perience, "  That  whether  adherent  or  not,  it  is  better 
to  remove  all  spicule,  and  thus  simplify  the  wound. 
If  these  be  retained,  endless  suppuration,  continued 
suffering,  with  exacerbations  of  all  the  S3'mptoms  at 
the  escape  of  each  small  fragment,  will  gradually  ex- 
haust the  vital  forces,  and  entail  its  sequelae  of 
marasmus,  diarrhoea,  and  hectic."  Suppuration  will 
eventually  bring  all  of  the  fragments  to  the  surface,  but 
at  what  a  sacrifice  ! 

McLeod,  after  quoting  the  experience  of  Roux, 
Baudens,  Guthrie,  Hutin,  Dupuytren,  Curling,  Begin, 
and  others,  on  the  dangers  of  allowing  movable  fras:- 
merits  to  remain,  and  the  necessity  of  extracting  every 
piece  which  is  not  extensively  attached  to  the  soft 
parts,  gives  his  experience  as  decidedly  in  favor  of  the 
modern  practice  of  removing  all  movable  spiculce  as  the 
best  mode  of  hastening  a  cure  and  diminishing  mor- 
tality, "  As  the  removal  must  tend  immensely  to  sim- 
plify the  wound." 

Again,  he  sa}*s:  "  The  extensive  comminution  of  the 
bone  by  a  conical  ball  makes  the  indications  with  re- 
gard to  the  management  of  the  sequestra  more  evident 
than  it  is  commonly  considered.  I  do  not  think  that 
%ve  paid  sufficient  attention  to  their  removal  in  the 
Bast.  It  may  be  true,  as  some  tell  us,  that  in  fract- 
ures with  the  old  ball  it  was  desirable  to  meddle  as 
little  as  possible  with  the  fragments;  but  this  is  the 
teaching  of  only  a  few.  However,  t6  my  mind,  the 
question  assumes  a  totally  different  light  when  viewed 
by  the  pathological  results  which  we  had  occasion  to 
witness." 


3(J0  00NDTTT0N    OF    COMPO  •  I  URFJ. 

Some  sargeona  go  farther,  and  recommend  thai  not 
only  should  all  apiculsB  be  removed,  but  that  the  sharp, 
irregular  ends  of  the  bones  should  be  sawed  off.  'This 
suggestion  has  not  met  with  general  approval,  and  is 
spoken  of  by  Stromyer  and  Locfller  us  no  improve- 
ment. Their  experience  gave  a  larger  mortuary  list 
when  this  practice  was  attempted. 

There  is  no  doubt  that  the  removal  of  all  fragments 
will  expedite  the  cure.  In  Burgery,  whenever  we  are 
in  doubt,  we  should  always  give  the  patient  the  bene- 
fit of  it;  and  in  thesubject  under  consideration,  know- 
ing that  the  removal  of  the  attached  fragments,  which 
might  eventually  become  consolidated,  can  do  no 
harm,  while  leaving  them  in,  should  union  not  be 
obtained,  would  not  only  be  followed  by  serious  .lun- 
ger, much  annoyance,  and  Buffering,  but  would  event- 
ually require  removal,  we  should,  without  hesitation, 
give  the  patient  the  benefit  of  the  doubt,  and  remove 
all  of  them  ai   the  tirst  examination. 

If  a  compound  comminuted  fracture  from  a  gunshot 

WOUnd    be  examined  three  weeks  after   its  occurrence, 

it  will  be  found  that  the  limb  will  always  be  enlarged, 
the  tissues  oedematous,  the  muscles  softened,  orifices 
pouting,  from  which  laudihlc  pus  in  quantity  is  daily 
discharged,  and  ai  the  bottom  of  the  wound  the  probe 
comes  in  contact  with  denuded  pieces  of  bone,  which 
appear  movable  and  isolated  as  if  in  a  pouch.  If  an 
incision  is  made  bo  as  to  expose-  the  injured  hone,  a 
oavity  will  be  entered,  lined  with  a  granulating  pus- 
secreting  surface,  in  which  the  broken  pieces  Of  hone 
lie  denuded  of  their  periosteum,  isolated  from  all  con- 
nection with  the  soli  paii-.  and  perfectly  bleached  as 
ir  they  had  undergone  a  long  process  of  maceration. 
Some  fragments  which  .-till  remain  connected  with 
the  soft  surrounding   tissues  will    he  blanched  upon 


TREATMENT   OF   COMPOUND    FRACTURE.  367 

then*  free  side.  The  periosteum  which  attaches  them 
to  the  contiguous  tissuos  is  soft,  thick,  and  very  vas- 
eular,  adhering  closely  to  an  intermediary  substance 
of  spongy  texture — evidently  new  bone  in  process  of 
formation.  In  other  fragments  this  new  deposit  from 
the  thickened  periosteum  has  so  nearly  enveloped  the 
piece  of  bone  broken  from  the  shaft,  that  the  partially 
isolated  white  bone  can  not  be  separated  without 
breaking  through  this  newly-formed  shell.  The  white 
fragments  are  those  pieces  which  had  become  isolated 
from  the  soft  parts  by  the  force  of  the  projectile,  and, 
as  is  always  the  case,  have  been  killed,  as  it  wore, 
from  that  moment  and  until  removed,  either  slowly  by 
nature,  or  by  a  surgeon,  irritate  the  soft  parts  as  for- 
eign bodies,  and  excite  the  copious  discharge  of  pus 
from  the  wounds. 

The  incarcerated  fragments  are  such  as  were  still 
adhering  to  the  soft  parts  by  their  peviostial  surface, 
but  had  met  with  such  destruction  of  their  interstitial 
nutrient  vessels,  by  the  abrupture  of  the  shaft  and 
the  tearing  of  the  medullary  membrane,  as  to  be 
incapable  of  living.  They  remain  adherent  only  for  a 
time;  new  bone  is  formed  over  them;  gradually  they 
are  isolated  from  the  new  structure,  and  form,  as  do 
the  movable  fragments,  sequestra.  From  these  path- 
ological  developments  it  would  appear  that  the  de- 
tached fragments  are  at  once  destroyed,  and  those  still 
connected  to  the  soft  parts  have  their  nutrition  so  im- 
paired that  they  also  die  and  become  foreign  bodies. 

The  course  of  treatment  based  upon  pathology  is. 
then,  clearly  defined.  If  the  chief  cause  of  death  in 
compound  gunshot  fractures  is  from  irritation  of  the 
system,  and  from  the  profuse  discharge  of  pus  drain- 
ing off  the  life's  blood,  both  of  which  are  caused  by 
these  foreign   bodies,  the  army   surgeon    is  culpable 


368  TREATMENT   OF   COMPOUND    FRACTURE. 

who  attempts  to  treat  a  compound  fracture  without 
removing  all  such  fragments  of  bone  broken  off  from 
the  shaft  i > \  the  ball  in  its  passage,  whether  they  arc 
loose  or  not.  Besides  the  immense  number  of  victims 
which  the  grave  conceals,  the  Dumber  of  necrosed 
limbs  daily  appearing  before  our  examining  boards 
for  furloughs  and  discharges  show  sufficiently  the  neg- 
lect of  this  principle.  The  country  is  now  filled  with 
men  upon  whose  arms  and  legs  Buppurating  fistula- 
lead  to  exfoliated  fragments,  incarcerated  in  a  shell 
of  new  bone,  or  embedded  in  the  soft  parts,  and 
which  years  of  suffering  and  annoyance  have  not 
been  able  to  eliminate.  These  living  testimonials 
of  a  bad  practice  establish  a  rule  of  treatment  which 
we  should  never  swerve  from  except  when  it  is  im- 
possible of  performance,  viz:  in  gunshot  fracture  of 
the  long  bones  remove,  without  fail,  and  as  soon  after  the 
accident  as  possible,  all  fragments  of  bone.  Experience 
shows  that,  where  this  course  is  rigorously  pursued, 
the  duration  of  treatment  is  very  much  shortened,  and 
the  mortality  decidedly  diminished.  Our  marked  suc- 
cess in  the  treatment  of  compound  fracture,  as  shown 
by  the  reports  from  the  Surgeon^ leneral's  office,  can 
be  attributed,  in  a  measure,  to  the  general  adoption  of 
this  rule  of  practice. 

While  recommending  so  urgently  that  all  fragments 
be  removed,  1  am  averse  to  the  operation  of  cutting 
off  the    sharp   ends  of  fractured    hones,  as  these,   not 

having  their  circulation  materially  disturbed,  are  not 

liable  to  the  same  dangers  of  necrosis  as  are  the  frag- 
ments. Their  nutrition  is  well  Supported,  and  such 
ends  usually  consolidate.  Even  when  the  periosteum 
has  been  stripped  from  the  ends  for  some  distance,  de- 
struction docs  not  necessarily  follow — as  the  bone, 
through  its  immediate  vascularity,  may  become  soft- 


TREATMENT    OF    COMPOUND    FRACTURE.  liG'J 

oncd,  its  blood-vessels  enlarged,  and  granulations  for 

the  formation  of  new  bone  appear  upon  and  cover  the 
surface. 

Feeling  secure  that  we  have  removed  every  foreign 
body,  and  having  left  nothing  in  the  wound  which  is 
likely  to  retard  the  cure,  we  should  ignore  the  pres- 
ence of  the  wound  as  much  as  possible,  and  treat  the 
case  as  one  of  simple  fracture.  Inflammation  and 
suppuration  we  expect;  they  generally  accompany 
compound  fractures,  and  especially  those  connected 
With  gunshot  wounds;  and  remembering  the  long- 
continued  and  profuse  drain  which  will  establish  itself 
after  four  or  five  days,  we  should  be  careful  how  we 
make  use  of  active  antiphlogistic  treatment.  For  the 
first  week  or  ten  days  the  limb  may  be  stretched 
upon  a  pillow,  or  loosely  secured  to  a  broad,  long 
splint,  which  will  support  the  entire  extremity,  and 
prevent  all  movements  between  the  broken  ends.  Dur- 
ing this  period  we  confine  the  treatment  to  cold  wa- 
ter dressings,  either  by  iced  bladders,  applied  over 
compresses,  in  order  to  remove  the  injurious  effects  of 
its  direct  application,  or  by  the  process  of  irrigation — 
either  of  which,  when  judiciously  applied,  is  better  than 
the  continued  renewal  of  wet  cloths. 

When  we  speak  of  the  advantages  of  irrigation 
above  all  other  methods  of  treatment  for  keeping 
down  inflammatory  action,  we  do  not  refer  to  the 
abusive  mode  of  application  common  in  the  army,  of 
deluging  the  body  and  bedclothing  of  the  patient,  and 
keeping  him  for  days  in  this  saturated  state,  fre- 
quently chilled  by  the  evaporation  going  on  from 
the  entire  surface  of  his  body,  whenever  the  bed- 
clothes are  thrown  from  his  person.  Under  this  proc- 
ess we  have  not  been  surprised  to  hear  surgeons  com- 
plain that  pneumonia  has  frequently  developed  in  the 


JOINT    1N.li  BLIE8 

course  of  treatment,  and  thai  erysipelas  is  more  Lia- 
ble to  appear  in  auch  patients.  All  tl>  Sects 
are  only  obtained  when  the  water  dressing  is  strictly 
confined  t<>  the  vicinity  of  the  wound. 

The  general  treatment,  for  the  tirst  few  days,  or 

during  this  period  of  inflammatory  excitement,  con- 

■  !'  simple  diet,  rest,  quiet,  and  the  administration 

of  mild  diaphoretics,  with  the  Liberal  use  <>t'  opium. 

Tain  we  do  not  consider,  in  any  sense,  necessary  to 
the  healing  of  wounds,  and,  therefore,  have  always 
made  it  a  rule  in  practice  to  reduce  it  to  its  minimum. 
The  complete  annihilation  of  pain  will  neither  detract 
from  the  rapidity  of  healing,  nor  from  the  gratitude 
of  patients.  The  impropriety  of  active  cathartics 
will  be  at  once  evident  from  the  movements  made  nec- 
essary   by  their  action.     Bloodletting,   emetics,  and 

the  use  of  mercury  we  absolutely  discard,  as  always 
useless  and  injurious  in  the  treatment  of  any  Staj 
compound  fractures.  A.s  Boon  as  the  period  of  inflam- 
matory reaction  lias  subsided,  we  then  apply  Buch 
splints  and  bandages  to  the  limb  as  will  secure  quiet 
and  rest,  while  at  the  same  time  a  \'i\>i-  vent  is  allow- 
ed in  the  apparatus  for  the  escape  of  discharges  from 
the  wound.  This  opening  also  permits  the  application 
Of  water  dressings  t<.  the  wound. 

The  most  dangerous  fractures  of  the  extremities 
are  those  extending  into  a  joint,  and  involving  the 
heads  of  the  hones.  The  synovial  injury  adds  great- 
ly to  the  danger  of  the  oase,  and  in  former  tunes  was 
considered  nearly  a  fatal  oomplioation,  as  it  net 
tated  an  amputation  which,  under  the  ordinary  cir- 
cumstances attending  hospital  treatment,  was  not  far 
removed  from  a  fatal  termination. 

The  severity  vt'  the  Bymptoms  of  articular  injuries 

depends  upon   the  size  of  the  joint    and   the  character 


,  JOINT   INJURIES.  871 

of.  the  wound.  The  dangers  are,  at  times,  serious 
enough  with  even  the  smallest  puncture,  but  when 
the  wound  is  large  and  lacerated,  and  often  even 
when  it  is  apparently  trifling,  extensive  local  mischief 
and  constitutional  disturbance  ensues,  leading  with 
certainty  to  the  destruction  of  the  joint,  and  usually 
destroying  the  patient.  Hence,  in  the  days  of  John 
Bell,  the  united  experience  of  surgeons  considered 
wounds  of  joints  mortal.  Crimean  experience  corrob- 
orates John  Bell's  conclusions,  as  no  serious  injury 
to  the  large  joints  recovered  unless  the  limbs  were 
amputated  or  joints  resected.  The  great  danger  is 
not  in  the  serious  injuries,  as  these  cases  are  at  once 
operated  upon.  It  is  in  the  apparently  trivial  case, 
where,  from  the  very  small  size  of  the  wound,  we 
hope  that  no  trouble  will  supervene,  that  violent 
inflammation  shows  itself,  and  life  is  sacrificed. 

The  cold  water  treatment  of  wounds,  so  universally 
adopted  in  the  Confederate  army,  both  in  field  and 
hospital  practice,  shows  its  great  advantages  over  every 
Other  dressing,  even  in  this  hitherto  fatal  class  of 
injuries.  In  examining  the  reports  in  the  Surgeon- 
General's  office  we  find  that  a  fair  proportion  of  gun- 
shot wounds  of  joints  have  recovered,  where  no 
operation  was  attempted.  In  knee-joint  injuries, 
which,  when  not  operated  upon,  have  heretofore  been 
considered  as  always  fatal,  we  can  show  nearly  fifty 
per  cent,  of  cures.  Quiet,  rest,  immobility  of  the 
injured  joint,  cold  water  dressing  by  irrigation  pre- 
ferred, and  opium,  comprise  the  elements  of  success- 
ful treat  nient 


:172 


JOINT    INJURIES. 


CoiiKolitiatfii   Tabi*  of  fnjurii  <•/  Joint*}  trrrxt.,1  without  Amputntiqii, 

III    .Inn,     I  . 
miry    1,  1864— J  N    ■        •  ■     •    //•    />'<!'  r. 


Kumarka. 


= 

I 

-      B 

i. 

j 

■    3 

W    1  <    1 

Oanea  of  guiD-lint  injurv  ....     IT 

'. 11 

km  byloaii 

imb 4      1 




Percentage  of  mortality 86    00    07    100 

period  of  death 10    88 

Greatest 

Leaet         "       "         "  o     »; 


Average  period  of  recovery  132  l"l     OS 

■I 21  I  ■-Tii  240 

u  a  32    -js    a:, 


I6«     71 

286  lb' 


Of  il  I  with 

able  limt'H.  and  Jj 
with  anctaj  l"*»--i  jointa; 
remainder  no!  - 


Iii  comparing  the  table  of  injured  jointa  not  oper- 
ated upon  with  the  table  of  resections,  it  must  be 
remembered  thai  the  more  Berious  cases  were  operated 
upon.  If  these  lia<l  been  treated  without  resection  or 
amputation,  the  mortality  among  such  would  have 
been  very  heavy.  In  many  of  the  cases  above  report- 
ed, the  joint  was  simply  opened  withoul  injury  to  the 
bones,  while  in  all  cases  of  resection  halls  had  entered 
the  joint,  tearing  up  the  capsule  and,  in  mosl  instan- 
pushing  the  arti  tulating  surfaces,  and,  therefore, 
making  the  prognosis  much  more  serious. 

A  wounded  joint,  under  the  ordinary  hospital  treat- 
ment, will  exhibit  the  following  symptoms:  When  a 
ball  has  perforated  the  joint,  the  period  of  reaction  ia 
not  long  absent.  In  extensive  wounds  a  great  degree 
of  nervous  shock  accompanies  the  injury,  the  pationt 
lying  deadly  pale,  cold,  and  faint.  In  from  twenty-four 
to  forty-eight  hours  the  tissues  around  the  articulation 
become  hot,  swollen,  and  painful;  inflammation  lias 
ahvady  sid/.t'd    upon  the  synovial    membrane,  and  will 

soon  involve  all  the  structures.     All  these  symptoms 


JOINT    INJURIES.  373 

r 

rapidly  increase  until  they  become  excessive.  There 
is  no  rest  for  the  weary  sufferer,  who,  often  in  spite  of 
iced  applications  and  the  free  use  of  morphine,  with  the 
entire  arcana  of  antiphlogistic  remedies,  writhes  about 
in  unmitigated  agony.  If  the  aperture  leading  into 
the  joint  be  made  by  a  ball  or  piece  of  shell,  tho 
synovia  at  first,  and  in  two  or  three  days  pus,  freely 
escapes.  Should  the  entrance  into  the  joint  be  small, 
or  the  passage  oblique,  the  purulent  synovia  fills  and 
distends  the  joint,  adding  much  to  tho  pain,  which  is 
increased  by  the  irregular  spasmodic  contractions  of 
the  surrounding  muscles. 

Accompanying  these  local  symptoms  will  be  found 
a  high  grade  of  inflammatory  fever,  with  rigors,  great 
gastric  distress,  intense  thirst,  excessive  restlessness, 
and  with  such  an  amount  of  constitutional  disturbance 
as  sometimes  to  destroy  life  in  a  few  days.  As  the 
disease  advances,  abscesses  form  in  the  surrounding 
tissues  by  extension  of  the  inflammatory  process,  and 
in  a  few  days  open  continuous  passages  to  the  joint, 
from  which  a  constant  discharge  of  purulent  matter  ' 
escapes.  Should  the  patient  have  an  iron  constitu- 
tion, ami  the  case  terminates  successfully,  it  will  only 
bo  at  the  expense  of  time.  After  many  weeks,  or 
even  months  of  suffering,  emaciation,  and  hectic,  the 
discharge  will  gradually  cease ;  but  as  the  preceding 
inflammation  lias  drstroyed  the  cartilaginous  surfaces 
of  the  joints,  and  also  the  character  of  the  sjmovial 
membrane,  lymphy  deposits  will  so  mat  the  extremi- 
ties <>t'  the  bones  together  as  to  permit  of  but  little 
motion,  and  an  interstitial  deposit  in  the  tissues  sur- 
rounding tin'  articulation  will  restrain  all  motions  of 
the  tendons  and  inuseles  passing  in  this  neighborhood, 

anchylosis  being  the  usual  sequela;  of  a  suppurating 
joint.     In  dome  cases,  where  mechanical   means  arc 


pIAGNOSIS    01    ARTICULAR    IN.MRV. 

to  break  up  those  bands  i  as  the  inflam- 

matory stage  baa  paased,  movable  joints  have  been 
saved  ;  a-<  a  rule,  however,  b  stiff  join!  follows  articu- 
lar injury. 

[f  the  patient  be  not  destroyed  in  the  early  Bti 
of  the  disease  by  nervous  exhaustion  from  the  intense 
and  constant  pain,  or  by  erysipelas  and  pyemia,  in 
connection  with  the  irritative  fever  to  whioh  Buch 
joint  wounds  are  particularly  liable,  lie  Calls  a  prey  to 
hectic,  caused  by  the  continued  drain  from  the  disor- 
ganized joint — synovial  membrane,  cartilages,  and 
bones  forming  one  mass  of  disease.  In  severe  gunshot 
wounds  of  large  joints,  in  military  hospitals,  rarely 
does  the  patient  escape  with  life.  In  private  practice 
he  sometimes  recovers,  bul  even  under  the  most  ad- 
vantageous Circumstances  for  treatment    a   BUCCi 

case  is  rarely  Been,  and  then  usually  with  a  destroyed 
and  anchylosed  articulation.  As  the  results  in  injured 
joints  are  so  fatal,  Burgeons  had,  at  an  early  day. 
adopted  amputations  as  giving  the  only  chance  for  re- 
covery. In  recenl  years  conservative  Burgery  has 
introduced  the  operation  of  resection  as  affording  not 
only  the  means  nt'  preserving  life,  but  also  of  saving  a 
useful  limb. 

The  diagnosis  of  articular  injury  is  usually  evident 
from  the  direction  of  the  wound  and  from  the  escape 

Of  synovia;  at  times,  however,  when  the  Orifice  is 
small  and  the  wound  circuitous,  a  successful  diagnosis 

requires  much  ezperienceand  close  observation.  When 
possible,  a  consultation  should  always  be  had  over 

these  eases;  as  it  is  often  in  these  very  cas<  -  of  appar- 
ently trivial  injury  that  the  most  violent  reactionary 
symptoms  are  met  with,  and  that  a  fatal  issue  occurs, 
[f  left  nn  Operated  Upon,  the  apparently  trilling  won  ml. 
perforating   the  Joint,  might  lead    to  severe  crushing 


RESECTION    OF    .SHOULDER-JOINT.  375 

of  the  bones,  which,  if  left  unrecognized,  might  nearly 
be  considered  mortal ;  while,  if  the  joint  be  not  impli- 
cated, the  operation  of  resection  is  not  only  not  called 
for,  but  unnecessarily  risks  the  life  of  the  individual. 
The  urgent  necessity  for  an  accurate  diagnosis  is 
evident. 

For  injury  to  the  heads  of  bones  forming  the 
joints  in  the  upper  extremity  resection  is  particularly 
applicable,  and  this  operation  is  now  the  rule  of 
practice,  having  superseded  amputation  in  all  cases 
where  the  blood-vessels  and  nerves  around  the  joint 
are  not  involved  in  the  injury.  When  a  joint  has  in 
any  way  been  injured  by  a  gunshot  wound,  whether 
the  joint  has  been  largely  opened,  or  the  heads  of 
the  bones  forming  the  articulation  crushed,  as  soon  as 
the  excessive  shock  under  which  the  patient  may  he 
suffering  passes  off,  we  proceed  at  once  to  operate.  A 
primary  resection  is  as  much  called  for  as  a  primary 
amputation,  and  is  followed  by  as  successful  results. 
It  should,  be  performed  within  twenty-four  or  thirty- 
six  hours,  or  before  reaction  sets  in.  Such  cases  would 
do  much  better  if  the  patient  could  be  transferred  to 
the  general  hospital  prior  to  an  operation,  as  trans- 
portation is  difficult  and  dangerous  immediately  after 
the  resection,  from  the  difficulty  of  securing  the  limb 
from  movements.  Experience  has  so  establisbed  tbis 
fact  that,  in  eases  necessitating  a  long  and  tedious 
transportation,  the  rule  is  to  amputate  rather  than  to 
resect,  inasmuch  as  the  gravity  of  the  resection  is  very 
much  increased  by  the  transportation.  Should  the 
•  ■a-"  col  come  under  observation  until  reaction  hi 
in,  then,  by  general,  mild,  antiphlogistic  treatment. 
and  ice  bladders  or  cold  water  dressings  locally,  we 
await  the  establishment  of  suppuration — after  which 


:;7»>  RKiSEOTION    OF   BHOULDKR-JOINT. 

the  operation  might  be  attempted  with  good  prospects 

Of  SlU'i'os. 

The  results  of  the  primary  resection,  are  more  BU0- 
cessfal  than  the  secondary  ;  and  these  are,  in  turn, 
much  more  likely  to  Buooeed  than  when  the  operation 
is  performed  daring  the  stage  of  febrile  excitement. 

There  arc  three  or  lour  rules  necessary  in  all  cases 
of  resection,  and  which  should  not  be  forgotten  daring 
the  operation,  viz:  Make  the  incisions  for  exposing 
the  heads  of  the  bones  in  that  portion  of  the  extremity 
opposite  to  the  main  blood-vessels  and  nerves,  so  that 
these  may  not  be  exposed  to  injury.  If  possiblo,  make 
the  existing  wound  lio  in  the  line  of  operations,  and 
place  the  incisions  in  such  a  way  as  to  permit  a  con- 
tinued drain  from  the  joint.  Make  these  incisions 
free,  so  as  not  to  cramp  the  operator  in  turning  out 
the  heads  of  the  hones.  An  inch  added  to  the  incision 
does  not  increase  its  serious  character,  and  hastens 
the  operation.  Remove  most  of  the  synovial  mem- 
brane, and  save  as  much  periosteum  as  possible;  the 
one  is  prone  to  take  on  inflammation — the  other 
makes,  and  will,  to  a  certain  extent,  reproduce  the 
bone.  In  performing  secondary  resections,  the  re- 
moval of  all  the  diseased  synovial  membrane  bocomes 
one  of  the  first  elements  for  success. 

More  successes  are  obtained  from  resections  of  the 
shoulder-joint  than  from  an  operation  upon  any  other 
articulation — the  statistical  tables  of  the  final  results 
of  operations  in  favor  of  resection  being  conclusive 
over  amputations. 

In  examining  these  tables  take  into  consideration 
that  primary  operations  are  performed  upon  the  most 
serious  injuries;  the  cases  of  apparently  trivial  injury 
are  kept,  and  resection  found  necessary  during  the 
progress  of  the  case. 


RESECTION    OF    SHOULDER-JOINT. 


377 


CmiKnlidated  Tabic  of  Resections)  collated  from  records  in  the  Surgeon- 
General'*  office,  from  June  1,  1862,  to  February  1,  1864— prepared 
by  Surgeon  H.  Bacr,  P.  A.  C.  S. 


PllIMAUY. 

Bucoessful . . . 
Unsuccessful., 


Secondary. 
Sucoessfal 

In  successful.. . . 


Useful  Joints. 


c 

to 

13 

* 

«Jj 

CD 

o 

5 

hi 

P. 

H 

a 

Total 68 


28 

22 

2 

13 

3 

•• 

2 

20 

23 

1 

1 

1 

7 

6 

•• 

1 

1 

2 

7 

•• 

68 

54 

3 

2 

4 

131 


Consolidated  Tabic  of  Disarticulations,  made  up  from  records  in  the 
Surgeon-General' s  office,  from  June  1,  1862,  to  February  1,  1864 — pre- 
pared, by  Surgeon  H.  Baer. 


c 

s 

-d 

5s 

J 

. 

S 

00 

o 
A 
CO 

3 

hi 

» 

Primary. 

Cures 

Deaths 

Secondary. 

Cures 

Deaths 

Total*.... 


54 

3 

5 

'  1 

2 

25 

1 

2 

2 

3 

9 

2 

20 

1 

•• 

•• 

6 

108 

7 

7 

3 

11 

136 


*  Sixty-five  additional  cases  had  been  reported,  but,  as  the  results 
had  not  been  determined,  they  have  been  omitted  from  this  table. 


When  the  ball  litis  entered  directly  within  a  joint, 
only  the  surface  may  require  excision  ;  but  should  the 
head  of  tin*  bone  be  extensively  spiculatod,  we  must 
Pi 


TREATMENT    IN    EM 

«ui  Lack  to  the  sound  bone,  bVen  if  wo  are  compelled 
to  remove  four  or  five  inches  of  the  shaft  of  a  bone,  as 
was  successfully  done  firsl  by  Stromyer  for  a  gunshot 

injury,  .and  several  times  in  the  Confederate  service. 
Should  the  receiving  cavity  be  equally  Injured,  the 
fractured  portion  Bhould  be  removed.  The  rule  is, 
never  to  remove  more  of  the  hone  than  is  absolutely 
called  for,  and  not  to  open  the  medullary  cavity  if  it 
can  in  any  way  he  avoided. 

When  the  wound  has  been  cleansed  of  all  foreign 
hodies,  the  flap  is  replaced  and  secured  with  one  or 
two. points  of  suture.  As  adhesion  by  the  first  inten- 
tion is  not  usually  expected,  and  gives  no  advantage 
pver  the  final  result  by  granulation,  nice  adjustment 
along  the  entire  line  of  the  incision  is  not  necessary. 
An  opening  must  be  left  at  the  si  dependent  por- 
tion of  the  wound  for  drainage.  The  patient  is  then 
put  to  bed,  and  cold  water  dressings  applied.  Intlam- 
Diation  at  first  runs  high,  the  parts  around  .the  joint 
arc  much  swollen,  and  a  collection  soon  forms  within 
the  Cavity  from    which  the    hones  have  heen  removed. 

'I'hc  escape  <>t  this  decomposed  blood  ami  pas  from 
the  wound'gives  great  relief.     When  kept   in   by  the 

too  nice  adjust  me  nt  of  t  he  (lap,  the  collection  inci 

the  swelling,  osdema,  and  pain,  which  is  diffused  ove* 

the  neighboring  parts,  involving  the  chest  as  well  as 
arm.  When  suppuration  becomes  established  the 
swelling  and  pain  subside,  granulations  spring  up, 
and  eventually  close  the  wound.  In  tin-  meantime, 
the  divided  muscles  have  formed  new  relations.  By 
means  of  the  lymphy  exudation  they  become  more  or 
less  incorporated  with  the  surrounding  tissues,  and, 
by  attaching  themselves  around  the  cut  portion  of  the 

bone  form,  in  time,  a  dosed  capsule.  A  head  to  the 
bone    is    SOmetimeB,    in    a    measure,   formed;   in    other 


TREATMENT    IN    RESECTION.  379 

cases  the  end  of  the  bone  becomes  attached  to  the 
cavity  by  fibrinous  bands. 

As  suppuration  will  bo  excessive  and  often  long- 
continued,  nourishment  and  stimuli  will  be  required 
during  the  treatment.  "When  abscesses  form  in  the 
surrounding  cellular  tissue  they  should  be  opened. 
It  is  a  matter  of  but  little  importance  in  what  position 
the  limb  is  placed,  and  how  it  is  secured,  provided  its 
position  is  comfortable  to  the  sufferer.  The  uneasi- 
ness and  irritation  which  the  splints  and  bandages 
give,  do  much  to  prevent  success.  In  the  upper  ex- 
tremity it  matters  little  what  length  of  limb  the  pa- 
tient has,  provided  his  life  be  saved  and  the  convales- 
cence be  speedy.  A  shortened  arm  does  not  affect  its 
usefulness,  and  a  slightly  changed  direction  can  bo 
corrected  in  the  after-stages  of  the  treatment.  The 
most  effectual  management  is  the  simplest,  and  tedi- 
ous daily  dressings  are  to  be  discouraged.  Straight- 
ening the  limb  upon  the  bed,  a  pillow,  or  a  long,  broad 
splint,  without  complicated  or  elaborate  bandaging,  is 
the  best  and  most  comfortable  dressing  for  any  resec- 
tion. The  patient  is  kept  in  bed  until  the  suppu- 
rative stage  is  established,  when  he  will  be  permitted 
to  get  up.  His  arm  is  then  placed  in  a  sling,  and  the 
water  dressings  are  continued  until  a  complete  cure 
is  effected.  When  the  parts  are  nearly  eicatriaed  it 
will  be  time  enough  t<>  apply  the  tumefaction  hand- 
age  for  removing  the  oedema  of  the  limb.  Anchylosis 
rarely  follows  this  operation  in  the  shoulder-joint. 

Of  the  cases  of  resection  of  the  shoulder  performed 

in  the  Crimea  DUl  few  died;  and  all  those  saved  re- 
gained a  useful  limb,  possessing  all  the  motions,  with 
the  exception   of   those  of  the  deltoid,  Which   III  U  - 

Certain  extent,  paralyzed  from  the  division  of  its 

nerve-,    which    can  not   altogether    he   avoided   in    ex- 


380  RESECTION    OF    SHOULDER-JOINT. 

posing  the  head  of  the  bone.  As  a  proof  of  the 
efficacy  of  resection,  Stronger  excised  nineteen  shoul- 
der-joints with  a  loss  of  seven,  chiefly  from  pysemia. 
Of  eight  cases  in  which  the  operation  was  required, 
but,  from  some  mitigating  circumstances,  was  not 
performed,  five  died. 

Sixty-eight  cases  of  resection  of  the  shoulder-joint 
have  been  reported  to  the  Surgeon-General's  office,  of 
which  forty-eight  were  successfully  treated,  the  pa- 
tients regaining  very  useful  arms,  the  forearm  and 
hand  possessing  all  of  their  former  movements. 

Comparative   Table  of  Resections  of  the  Shoulder-joint. 


QQ 

J3 

a 

a 

rt 

O 

ft 

English  in  Crimea 16  3     I      H> 

French  in  Crimea 38  21  55 

Confederate  service 67  20  30 


This  operation  was  not  performed  as  frequently  as 
necessity  required.  Many  cases  of  necrosed  joints 
from  gunshot  wounds  of  the  shoulder  are  daily  apply- 
ing to  examining  boards  for  extension  of  furlough,  in 
which  an  anchylosed  joint,  with  useless  and  impov- 
erished limb,  exists,  and  also  fistuhe  of  many  months, 
and  even  two  and  three  years'  duration,  from  which 
is  kept  up  a  thin,  ichorous  discharge,  with  the  period- 
ical escape  of  pieces  of  bone. 

Gunshot  wounds  in  the  neighborhood  of  the  elbow- 
joint  are  much  more  readily  recognized,  by  the  escape 
of  the  synovia,  etc.,  than  injuries  of  the  shoulder.  In- 
flammatory reaction  runs  high,  as  in  all  cases  in 
which  joints  have  been  opened  by  a  ball.     Collections 


RESECTION    OF    SHOULDER-JOINT.  381 

soon  form,  and  the  excessive  swelling  stretches  the 
softened  capsule,  which,  giving  way,  allows  of  the 
burrowing  of  pus  and  final  discharge  through  open 
abscesses.  After  running  a  tedious,  painful,  and  dan- 
.gcrous  course,  if  the  patient  escapes  with  a  shattered 
constitution  and  an  anehylosed  limb,  it  is  as  much  as 
he  can  expect.  When  the  bones  forming  the  elbow 
are  not  involved,  the  treatment  consists  in  repose, 
keeping  the  joint  immovable,  with  the  free  applica- 
tion of  cold  water,  and  the*  administration  of  opium 
to  allay  pain  and  quiet  nervous  excitement. 

Should  the  wound  be  of  such  a  character  as  would 
probably  be  followed  by  disastrous  inflammation,  then 
a  primary  resection  offers  a  diminution  of  the  risks 
to  life,  a  rapid  convalescence,  and  a  movable  joint. 
In  the  Schleswig-Holstein  army,  of  fifty-four  amputa- 
tions of  the  arm,  nineteen  died;  while  of  fort}T  resec- 
tions, under  similar  circumstances,  only  six  died.  In 
the  Confederate  service,  of  two  hundred  and  fifty  casos 
of  amputation  of  the  arm  there  were  sixty-five  deaths, 
while  in  forty-five  resections  of  the  elbow  there  were 
nine  deaths.  The  results  of  the  operations  were  also 
modified  by  the  period  at  which  the  resection  was 
performed.  Of  eleven  cases  excised  within  twenty- 
four  hours  before  reaction  ensued,  but  one  died  ;  of 
twenty  cases  between  the  second  and  fourth  day,  or 
during  the  stage  of  irritation  or  excitement,  four  died  ; 
and  of  nine  cases  operated  upon  between  the  eighth 
and  thirty-seventh  day.  only  one  died — an  exemplifi- 
cation of  a  general  rule  laid  down  in  the  commence- 
ment of  this  chapter,  that  the  wounded  bear  opera- 
tions before  the  Btage  of  reaction,  or  after  the  estab- 
lishment of  suppuration,  much  better  than  they  do 
while  suffering  under  high  inflammatory  excitement. 
This  shows  the  necessity  of  deferring  secondary  opera- 


382  TREATMENT    OF    EUACTUUED    ARMS. 

tions  until  the  proper  time  has  arrived   which  experi- 
ence has  determined. 

It  can  not  he  expected  that  an  arm,  after  a  serious 
gunshot  injury  to  the  bones,  will  be  cured  without 
deformity.  The  arm  will  always  be  shortened,  where  i 
many  spicuhe  have  been  removed.  We  acknowledge 
this  fact  in  anticipation,  and  never  attempt,  by  trac- 
tion and  counter-extension,  to  i*estore  it  to  its  former 
length.  AVe  simpty  place  the  arm  in  an  easy  position, 
and  allow  the  muscles  to  •approach  the  broken  ends. 
This  course  is  opposed  to  that  adopted  in  the  treat- 
ment of  simple  fractui'es,  where  the  main  object  is 
to  prevent  deformity,  and,  especially,  shortening  of 
the  limb.  As  this  object  is  discarded  in  compound 
fractures  of  the  upper  extremity,  the  treatment  is 
thereby  much  simplified,  and  the  patient  is  saved  much 
annoyance  and  suffering. 

In  simple  fractures  of  the  arm,  the  pasteboard  splints 
are  to  be  preferred ;  while,  for  the  forearm,  wooden 
splints,  made'of  light  material,  and  wider  than  the  diam- 
eter of  the  arm,  will  make  the  best  application.  The 
tumefaction  bandage  is  not  required,  and  in  gunshot 
fractures  is  altogether  discarded.  In  gunshot  injuries, 
where  we  have  an  open  wound  to  dress  daily,  our 
mechanical  applications  should  be  of  such  a  character 
as  to  permit  of  easy  inspection,  and  also  the  ready- 
readjustment  of  the  apparatus  when  disarranged, 
while,  at  the  same  time,  the  splints  are  kept  secure. 
The  serious  objection  to  bandaging  compound  fract- 
ures is  in  the  abundant  discharge  saturating  the 
dressing,  and  in  summer  rendering  it  necessary  to 
renew  it  daily,  if  not  twice  a  day.  Every  movement 
of  the  broken  limb  being  very  painful,  but  little  hand- 
aging  should  be  used,  so  that  the  wound  is  open  to 
inspection,  and  the  limb  can  be  daily  dressed  without 


TREATMENT    OF    FRACTURED    ARMS.  383 

disturbing  its  position.  Diachylon  plaster  is  now 
extensively  used  to  secure  splints  to  fractured  limbs 
three  or  four  bands  encircling  tbe  limb  will  always 
retain  the  supporting  apparatus,  While  the  limb,  at 
its  wounded  portion,  remains  uncovered.  When  the 
pasteboard  is  moistened,  it  moulds  itself  to  the  arm 
and  makes  a  very  satisfactory  dressing. 

As  soon  as  the  patient  has  passed  the  reactive  stage 
he  should  no  longer  be  confined  to  his  bed,  but,  with 
his  arm  in  a  sling,  may  obtain  sufficient  exercise  to 
keep  his  system  in  good  condition.  The  erect  position 
•will  have  the  additional  advantage  of  permitting  the 
ready  discharge  of  pus  and  prevent  the  bagging  of 
this  fluid,  and  will  obviate  the  necessity  for  the  estab- 
lishment of  counter-openings.  In  all  simple  fractures 
the  excess  of  callus  depends  upon  the  degree  of  mo- 
bility between  the  broken  ends.  In  compound  fract- 
ures the  deposit  for  consolidation  is  usually  very 
great,  which  may  be  explained  by  the  amount  of 
irritation  from  inflammatory  action,  and  also  by  the 
difficulty  of  keeping  the  fragments  at  rest.  Fortu- 
nately this  does  not  interfere  with  the  final  results,  as 
false  joints  are  not  more  frequently  met  with  in  com- 
pound than  in  simple  fractures.  Experience  shows 
us  that  there  is  not  that  necessity,  winch  many  prac- 
tice, of  frequently  tightening  the  apparatus,  to  the 
very  great  annoyance  of  the  patient.  If  the  consti- 
tution be  strong,  a  considerable  degree  of  relaxation 
may  be  permitted,  and  be  found  not  incompatible  with 
perfect  consolidation.  In  animals  with  compound 
fractures  we  Bee  continual  exemplifications  of  this 
fact — their  broken  bones  becoming  united,  notwith- 
standing the  continued  motions  of  the  limb,  in  the 
absence  of  all  retentive  apparatus. 

The  local  and  general  treatment  of  the  wound  will, 


384  TREATMENT    OF    FRACTURED    ARMS. 

in  no  respect,  be  modified  on  account  of  the  fracture. 
Water  dressings,  until  cicatrization  is  completed,  med- 
icated with  aBtringents  to  allay  profuse  discharges,  or 
with  antiseptics  to  remove  fetor,  or  with  stimuli  to 
promote  granulations,  will  be  the  proper  course,  while 
the  general  health  is  watched,  retarded  secretions 
promoted,  and  debility  guarded  against.  If  fragments 
of  bone  have  remained  and  have  become  necrosed, 
the  Burgeon  must  assist  nature  in  their  expulsion, 
otherwise  they  will  be  surrounded  by  new  formations, 
and,  as  sequestra,  incarcerated  in  an  involucrum,  will 
only  be  expelled  after  much  time  and  trouble.  When 
spiculae  are  suspected,  the  wound  should  be  examined 
from  time  to  time,  and  especially  about  the  eighth  or 
tenth  day  from  the  receipt  of  injury,  when  the  swell- 
ing has  subsided  to  such  an  extent  that  the  finger  can 
l>e  introduced.  During  the  excitement  of  reaction  all 
examinations  of  the  wound  should  he  interdicted.  As 
soon  as  we  conclude  that  all  fragments  have  been 
removed,  we  desist  from  further  probing,  as  it  can  not 
hut  he  injurious  to  the  delicate  granulations. 

Cleanliness  is  necessary  to  successful  hospital  prac- 
tice in  the  treatment  of  suppurating  wounds,  but, 
when  excessive,  becomes  a  serious  obstacle  to  rapid 
cicatrization.  It  is  a  common  error  for  surgeons  to 
place  a  wounded  limb  over  a  basin  of  water,  and 
sponge  and  rub  it  as  if  they  were  cleansing  a  piece  of 
porcelain.  I  have  seen  others  cleanse  gunshot  wounds 
by  the  free  use  of  a  powerful  syringe,  with  which 
they  poured  a  stream  of  water  into  the  wound  until 
the  granulations  were  bleached  and  the  water  re- 
turned discolored  with  blood,  and  this  repeated  with 
great  regularity  at  the  morning  and  evening  visit. 
It  was  not  surprising  that  wounds,  treated  with  this 
ovor-care,  took  a  very  long  time  to  heal. 


TREATMENT    OF   FRACTURED   ARMS.  385 

This  too  liberal  use  of  the  syringe  is  a  very  common 
error  with  surgeons,  who  overlook  the  protective  in- 
fluence of  healthy  pus  in  their  over-estimate  of  exces- 
sive cleanliness.  I  have  seen  a  surgeon,  in  a  case  of 
resection  of  the  shoulder-joint  which  promised  a 
speedy  and  successful  cure,  put  the  beak  of  a  syringe 
into  one  of  two  or  three  fistulous  tracks  by  which  the 
ligatures  had  escaped,  and  distend  the  cavity  until  jets 
d'eau  spouted  from  the  opposite  orifices,  the  perp  si  ra- 
tion streaming  from  the  lace  of  the  patient,  and  the 
distorted  countenance  indicating  the  unnecessary  tort- 
ure which  the  surgeon  Avas  inflicting.  Was  it  singular 
that  the  case  retrograded  from  the  time  this  rude  and 
ignorant  practice  was  instituted  ?  and  could  any  other 
result  have  been  reasonably  expected? 

If  the  wound  be  gangrenous,  and  the  object  be  to 
remove  ichorous  decomposing  fluids,  to  diminish  or 
prevent  absorption  and  general  poisoning,  then  the 
syringing  is  desirable;  but  under  no  other  conditions 
should  the  granulating  surface  of  a  Avound  be  washed. 
Wipe  around  the  edges  and'  remove  an}  secretions 
which  might  have  collected  upon  the  skin,  but  leave 
the  pus,  as  the  best  covering  which  healthy  granula- 
tions can  have.  Under  its  protection  the  plasma, 
which  is  thrown  out  from  the  blood-vessels,  Avill  rapidly 
form  tissues ;  but  rub  or  wash  away  this  covering,  and 
the  exposure  to  the  baneful  influences  of  the  atmos- 
phere Avill  rapidly  destroy  the  granulations  which  had 
already  formed.  However  useful  the  local  and  general 
bath  is  to  advance  the  cicatrization  of  a  suppurating 
Wound,  do  not  generalize  too  much,  and  expect  equally 
good  service  from  cleansing  the  granulations. 

Compound  fractures,  under  the  very  besl  conditions, 
are  tedious  cases,  and  in  gunshol  injuries  our  patience 
will  often  be  taxed  to  the  utmost.  Despondency  should 
Ga 


METI10D    FOB    RESECTING    ELBOW-JOINT. 

not  be  an  element  in  the  character  of  a  military  Bur- 
on.     We  must  expect  to  have  a  compound  fracture 
under  treatment  at  least  twice  it'  not    three  times 
long  as  would  bo  required  to  consolidate  a  simple  fract- 
ure. 

Should  the  main  vessel  be  injured,  in  connection 
with  the  fractured  bones,  weliavo  m»t  sufficient  cause 
to  sacrifice  the  limb;  but,  ligating  the  artery  at  its 
bleeding  mouths,  we  treat  the  fracture  as  if  this  com- 
plication had  not  existed.  Owing  to  the  free  anasto- 
mosis of  the  blood-vessels  of  the  arm,  mortification  is 
not  to  be  feared  when  a  ligation  is  applied  even  to  the 
brachial  artery;  a  circuitous  route  soon  supplies  the 
needful  nourishment  to  the  parts  beyond.  Should  the 
neivi  b  as  well  as  the  artery  be  injured,  or  the  principal 
nerves  be  divided  with  the  bones,  then  the  limb,  even 
when  saved,  would  bo  a  useless,  paralyzed  extremity) 
and  its  immediate  removal  will  sa\  e  the  patient  a  long, 

h  di0U8,  and  dangerous  convalescence.  We  pursue  a 
similar  course  when  the  soft  parts  are  extensively 
lacerated.  In  euch  cases  it  is  our  duty  to  sacrifice  the 
limb  to  diminish  the  risks  to  life, 

The  elbow-joint,  for  gunshot  wounds,  transfixing  its 
capsule  and  fracturing  the  bones,  is  best  rosocted  from 
the  back  of  the  joint,  the  patient  lying  upon  his  abdo- 
men. There  are  no  important  vessols  on  this  posterior 
portion  of  the  arm,  and  only  one  nerve— the  ulna — 
which  must  be  sought  on  the  inner  side  and  avoided 
in  the  incision,  or  paralysis  of  all  the  muscles  supplied 
by  it  will  follow  its  section.  W 1 1 * •  1 1  tho  posterior  liga- 
ments aro  divided  and  the  joint  exposed,  only  remove 
the  fractured  head  and  all  foreign  bodies,  and  do  not 
interfere  with  that  bone  which  has  not  been  injured. 
The  lips  of  the  wound  are  cloi  od  by  sutures,  and  cold 
ngs  be<  ome  the  pi  incipal  treatment.     The 


RESECTION    OF   WRIST-JOINT.  387 

limb  is  placed  upon  a  pillow,  and  not  disturbed,  if 
possible,  until  suppuration  is  established.  "When  the 
soft  parts  are  cicatrizing,  and  healing  is  nearly  com- 
pleted, passive  motions  in  the  joint  will  prevent  anch- 
ylosis, and  a  tumefaction  bandage  will  removo  the 
oedema  of  the  limb. 

Instances  of  successful  resections  are  recorded  for 
injuries  at  the  wrist-joint,  where  the  spiculated  ends 
of  both  radius  and  ulna  have  been  satisfactorily  re- 
moved ;  also,  instances  in  which  either  of  these  bones 
have  been  removed  entire,  for  chronic  ostitis  and 
necrosis  brought  on  from  gunshot  injuries.  Similar 
incisions  to  those  recommended  for  the  resection  of 
(he  elbow-joint  will  expose  the  heads  of  the  wrist 
bones,  and  permit  of  the  ready  removal  of  any  injured 
portion.  In  this,  as  in  all  other  cases,  we  must  save 
all  tendons  passing  over  a  joint  to  supply  distant 
bones;  and  in  the  wrist,  particularly,  many  of  tho 
muscles  which  supply  the  fingers  can  be  drawn  out  of 
the  way,  and  thus  escape  section. 

When  a  ball  perforates  a  wrist-joint,  although  in- 
flammation will  run  high,  with  much  persistent  swell- 
ing, pouting  orifices,  and  profuse  discharge,  such  cases, 
with  patience  and  cold  water  dressings,  will  event- 
ually do  well.  This  is  an  instance  of  gunshot  wound 
of  a  joint,  with  fracture  of  the  bones,  which  rarely  _ 
requires  amputation.  In  such  injuries  the  hand  aid 
forearm  is  carried  upon  a  straight  splint  until  the 
inflammation  and  swelling  subside,  when  great  care 
must  he  taken  to  avoid  the  contraction  of  the  fingers 
and  hand  by  using  daily  passive  motion's  and  by  rub- 
bing with  su<h  stimulating  embrocations  as  will  pro- 
tie-  absorption  of  deposits  in  and  around  the 
sheaths  of  the  tendon-. 

Sow    "i  frightful  an  injur)  involves  the  band,  li  is 


3S8  SAVE    ALL   PARTS    OF    HAND. 

very  seldom  that  it  is  so  mangled  as  to  1"'  beyond  the 
pale  of  surgical  skill,  and  unless  it  is  literally  ground 
up  it  should  not  bo  amputated.  In  certain  cases 
fingers  may  have  been  already  torn  off,  or  may  be 
hanging  by  a  fragment  of  skin,  when  they  should  be 
removed  ;  but  for  ordinary  gunshot  lacerations  of  the 
hand,  amputation  of  the  entire  hand  is  very  rarely 
required. 

Different  bones  of  the  hand  and  wrist  are  to  be  re- 
moved when  irrevocably  injured,  with  or  without  the 
metacarpal  bones  of  the  fingers  or  the  thumb.  Any 
fingers  which  can  he  saved  will  be  better  than  the 
West  artificial  limb.  In  eases  of  lacerated  hands,  in 
military  surgery,  when  attempts  are  made  to  save  the 
limb  under  cold  water  dressings,  the  inflammation 
which  comes  on  makes  a  shocking  limit  to  those-  unac- 
customed to  treat  lacerations  of  this  extremity;  but 
at  the  end  of  eight  or  ten  days,  when  suppuration  has 
hern  well  established  and  granulations  are  forming, 
the  swelling  subsides,  the  torn  portions  are  drawn 
together,  cicatrization  advances  rapidly,  and  often  hut 
little  deformity  remains;  at  least,  the  patient  retains 
a  useful  limb.  Some  surgeons  lay  down  the  rule  that 
an  amputation  of  the  hand  is  never  imperative,  how- 
ever frightful  the  injury  to  it  may  appear;  and  there 
is  much  truth  in  the  assertion. 

In  the  inferior  extremity  wo  find  the  treatment  of 
gunshot  injuries  somewhat  different  from  those  of  the 
Upper  limb,  on  account  of  the  minor  degree  of  vascu- 
larity, and  the  much  greater  tendoncy  to  mortification, 
so  that  the  rule  to  which  we  called  attention,  of  ampu- 
tations being  rarely  required  for  the  superior  ex- 
tremity, is  reversed  for  the  leg,  where  it  is  often  the 
Only  way  of  escape  left   to  save  the  life  of  the  wounded. 

We  have  elsewhere  stated  that  when  balls  embedded 


THIGH    FRACTURES.  889 

themselves  in  the  pelvic  bones,  and  their  position 
could  be  discovered,  provided  a  serious  operation  is 
not  needed,  they  should  be  removed,  as  their  presence 
will,  sooner  or  later,  give  rise  to  trouble.  All  loose 
spicuhe  should  also  be  taken  away,  and,  as  sequestra, 
frequently  show  themselves  from  time  to  time  during 
the  treatment,  they  should  be  withdrawn. 

When  the  ball  strikes  lower  down,  in  the  neighbor- 
hood of  the  trochanters,  it  usually  splinters  the  bone, 
and  frequently  involves  the  ilio-femoral  articulation. 
Such  injuries  are  of  the  most  serious  character,  and 
are  usually  considered  fatal.  It  is  a  question  of  much 
moment  to  inquire  how  can  modern  surgery,  with  all 
of  its  appliances,  improvements,  and  experience,  as- 
sist in  saving  the  life  and  limb  of  such  seriously 
wounded  ?  Within  a  few  years  the  rule  for  all  com- 
pound fractures  of  the  femur  was  amputation  of  the 
limb;  but  the  statistics  from  military  hospitals  in  time 
of  war  are  so  frightful — but  few  successes  for  the  num- 
bers treated — that  it  was  naturally  suggested  that  the 
risks  could  not  be  materially  increased  by  letting  the 
patient  take  the  chances  with  his  limb  on;  when,  if 
his  life  were  saved,  it  would  be  with  and  not  without 
his  leg.  This  hag  settled  down  into  a  conviction  for 
fractures  of  the  upper  third  of  the  femur,  which  are 
now  treated  without  amputation,  inasmuch  as  nearly 
every  amputation  in  the  neighborhood  of  the  trochan- 
ter, and,  with  very  rare  exceptions,  all  at  the  hip-joint, 
are  fatal. 

It' we  are  assured  that  the  ball  has  crushed  the  head 
of  the  bone,  then  the  operation  of  resection  offers  the 
best  prospects  of  success  for  the  patient;  but  it  does 
not  always  follow  that  this  diagnosis  can  be  clearly 
made  out,  if  the  signs  of  intracapsular  fracture  be  Q01 
at.     -Military  surgical  experience  shows   that  a 


RESECTION    OP    HIP-JOINT. 

fracture  of  the  upper  portion  of  the  shaft  of  a  hone 
does  not  necessarily  extend  into  the  head,  and  vice 
versa.  Unless  the  junction  of  the  epiphysis  with  the 
shaft  is  struck',  the  fracture  is  more  likely  to  be  con- 
fined to  a  centre  of  ossification — so  that  in  the  thigh, 
as  in  the  arm,  a  blow  just  below  the  trochanter  will 
not  usually  fracture  the  head  of  the  femur.  When 
the  joint  is  opened  and  the  head  of  the  bone  fractured, 
the  wound  should  be  enlarged,  or  an  opening  made 
into  the  joint  from  the  outer  side  of  the  hip.  by  which 
the  fractured  head  might  be  removed. 

If  any  success  is  hoped  for,  those  cases  alone  should 
be  selected  in  which  neither  blood-vessels  or  nerves 
are  injured,  nor  the  soft  parts  extensively  torn.  If  all 
or  any  of  such  are  involved,  where  experience  teaches 
us  that  the  chances  for  successful  resection  are  more 
than  doubtful,  do  not  have  recourse  to  amputation, 
which  is  so  certainly  fatal,  but  let  the  patient  live  his 
few  remaining  hours  or  days  without  being  haunted 
by  the  ghost  of  a  useless  operation.  Should  he  revive 
the  reactionary  stage,  and  still  retain  a  good  pulse  and 
comparatively  unshattered  constitution,  then  a  second- 
ary operation  might  give  a  chance  of  success.  In  the 
Crimean  service  no  amputation  in  the  vicinity  of  the 
hip-joint  was  successful — every  individual  case  died. 
In  the  Confederate  service  but  one  successful  case  of 
primary  amputation  at  the  hip-joint  is  reported.  This 
only  corroborates  the  experience  of  other  campaigns, 
and  also  shows  the  inutility  of  such  mutilations. 
When  death  from  a  crushed  thigh-joint  is  inevitable,  it 
is  hardly  humane  to  amputate  under  the  plea  of  giving 
to  the  patient  the  benefit  of  the  chances  which  experi- 
ence teaches  us  are  nugatory. 

As  regards  resections  in  suitable  cases,  the  report  is 
a  little  more  satisfactory.     Of  six  resections  performed 


RESECTION   OF    HIP-JOINT.  391 

by  the  English  Burgeons  in  the  Crimea  one  was  suc- 
cessful, and  the  condition  of  all  operated  upon  was 
made  more  comfortable.  Had  the  conveniences  for 
treatment  been  greater,  and  the  general  sanitary  con- 
dition of  the  troops  better,  with  less  pyaemia,  hospital 
gangrene,  cholera,  and  scurvy,  much  better  results 
might  have  been  obtained.  Some  of  the  cases  were 
doing  well,  with  every  prospect  of  final  success,  when 
they  were  swept  off  by  one  of  the  above  diseases.  Ln 
amputations  at  the  hip-joint  all  the  cases  died  speedily. 

In  cases  of  resection,  the  greatest  difficulty  lies  in 
the  after-treatment.  As  it  is  not  expected  to  restore  a 
perfect  limb,  no  good  result  can  be  obtained  by  using 
violent  extension.  The  leg,  however,  must  be  fixed,  to 
facilitate  those  movements  in  the  changing  of  position, 
Which  are  necessary  to  the  patient's  comfort.  A  long, 
straight  splint  is  used  for  this  purpose  by  some  sur- 
geons, while  the  inclined  piano,  or  Smith's  anterior 
splint,  which  I  would  much  prefer,  is  depended  upon 
b}'  others.  Some  have  bandaged  the  limb  to  the 
sound  one,  and  speak  of  it  as  a  good  mode  of  support. 
Water  dressings  compose  the  local  treatment. 

Baudens  succeeded  in  saving  both  limb  and  life  in 
-cases  in  which  compound  fractures  of  the  upper  half 
of  the  thigh  were  treated  without  operation.  Consoli- 
dated and  useful  limbs,  with  but  little  deformity,  are 
reported  as  having  been  saved.  By  the  use  of  the 
fracture-box  and  inclined  plane  he  succeeded  in  curing 
a  compound  fracture  on  a  level  with  the  trochanter — 
saving  a  useful  limb,  although  he  had  extracted  two 
inches  of  the  shaft  of  the  femur.  His  experience 
proves  that  compound  comminute  1  fractures  of  the 
upper  half  of  the  thigh  are  not  so  fatal  when  attempts 
are  made  to  save  the  limb  as  when  the  thigh  is  ampu- 
tated.    The  experience  of  surgeons,  derived  from  the 


392  BESKCTION    OF    HIP  .MUM'. 

wounded  of  the  Confederate  campaigns,  would  estab- 
lish a  similar  course  of  treatment,  as  excellent  limbs 
were  saved  where  fractures  had  occurred  in  the  upper 
third  of  the  femur,  while  amputations  in  the  immedi- 
ate neighborhood  of  the  trochanters  mol  with  the  usual 
fatality.        ^ 

As  the  resection  of  the  hip  is  so  much  more  success- 
ful when  performed  fur  disease  than  for  injury,  it  has 
been  suggested,  by  surgeons  of  experience,  that  an  ex- 
ception to  the  rule  of  immediate  resections  be  made 
for  the  hip-joint,  and  that  such  eases,  even  the  most 
suitable  for  the  operation,  be  deferred  until  suppura- 
tion is  well  established.  For  hip-joint  resections  it  is 
said  that  nothing  is  lost  by  this  delay,  while,  on  I  lie 
contrary,  there  may  be  a  chance  of  saving  the  limb 
without  an  operation.  Larrey,  in  1S12,  reported  six 
eases  of  gunshot  fractures  of  the  neck  of  the  femur, 
with  three  cures — showing  that  the  prospects  are  not 
altogether  hopeless.  "When  the  patient  is,  in  a  meas- 
ure, placed  in  a  similar  condition  to  those  affected 
with  diseases  of  the  bones,  his  prospect  for  a  success- 
ful resection  appears  to  be  improved.  Baudens  says 
that,  as  the  resection  of  the  hip-joint  only  succeeds  as 
a  secondary  operation,  attempts  should  first  be  made 
to  save  the  limb. 

"We  preface  the  following  table,  taken  from  Ar- 
mand's  Jlistuire  Medico- Chiruryica I e  Je  la  Guerre  </<■ 
Crimee,  with  the  suggestion  that  any  surgeon  who  has 
ever  had  a  successful  case  of  resection  at  the  hip-joint 
has  always  been  eager  to  publish  it,  while  many  have 
been  disposed  to  hide  their  misfortunes  from  the  pub- 
lic— so  that  the  tables,  showing  the  relative  advan- 
tages of  primary  and  secondary  resections,  appear  in 
their  very  best  light. 


RESECTION    OF    Hll'-. HUNT. 


393 


Primary  Resections  after  Gunshot  Wounds. 


Suiiu  eons. 


Operated  n 

Cur 
upon. 


Deaths. 


Larrey.     (Volume  3,  Clinique) 

J.  Cooper.     (Dictionary) 

Leteillo.      (Relatione  du  Siege  d'Anvcrs  par 

M.   II.  Larrey) 

IIu^u.     (Memoircs  dc  Medicine  et  de  Chi- 

rnrgie  Mil  it  aires) 

Esedillot.      (Annates   de  la   Chirurgic  Fran- 

oaise  el  Etrangere) 

Duyon.     (Expedition  de  Churchill,  Algere 

Ruehct.     (Journees  de  Juin.  1848) 

Gubiot.     (These  de  Montpellier,  1840) 

French  Crimean  Service 

McLcod.     (Crimean  War) 

Stromycr 


1* 


5 
1 
1 
3 
9 
4 
1 

36 


*  This  successful  case  was  found,  after  the  articulation  had  been  laid 
open,  not  to  be  a  fracture  extending  within  the  joint,  but  confined 
without  the  capsule;  and  we  are,  therefore,  justified  in  the  belief  that 
the  case  would  have  done  equally  well  without  the  resection. 


Secondary  Resections  after  Gunshot  Wounds. 


Surgeons. 


Operated 
upon. 


Cures.   Deaths. 


Larrey.     (Clinique,  volume  5) 

Guthrie.     (Clinic,  volume  5) 

Baudens.     (Traite  des  Plaice  d'Armes  a  feu) 
Ferussac.     (Bulletin  des  Science  Medical es, 

volume  3) 

Robert.     (Journees  dc  Juin,  1848) 

GuersanL     (Journees  de  Juin,  1848) 

Vidal.     (Traite  de  Chirurgie) 

Mounier.     (Constantinople,  1854) 

Legouest.     i  Constantinople,  1854 ) 

McLcod.     ( Crimean  War) 


12 


The  reports  of  hip-joint  resections  at  the  Surgeon- 
General's  office  are  exceedingly  meagre.  I  know  of 
several  unsuccessful  cases  of  primary  resection,  and 
two  oases  of  successful  operation,  in  one  of  which  the 


394 


I  DRE    IN    I'l'I'KIt   THIRD. 


patient  could  walk  well  by  using  a  cane.  The  num- 
ber of  eases  is  not  known,  however,  with  sufficient 
certainty  to  offer  any  percentage  of  coxes. 

It  lias  been  suggested  that,  it'  the  patient  who  lias 
been  operated  upon  could  have  facilities  for  slinging 
the  whole  body,  it  would  afford  many  advantages  in 
the  management  of  excisions  of  the  hip-joint. 

A  compound  fracture  in  the  upper  third  of  the  thigh 
should  be  treated,  in  every  respect,  as  if  in  tin- arm. 
Unless  the  leg  is  so  mangled  that  an  amputation  is  an 
act  of  necessity,  it  should  not  be  thought  of.  We  have 
already  said  that,  in  field  military  surgery,  amputa- 
tion of  the  thigh  in  the  immediate  vicinity  of  the 
trunk  is  nearly  synonymous  with  death,  while  many 
gunshot  fractures  in  this  region  are  saved.  The  fol- 
lowing tal-les  will  throw   much   light  on  this  subject. 

Contolidated  Table  of  Compound  Fracture  of  th>>  Thigh,  treated  without 
amputation,  made  iip  from  records  in  Surgeon-General's  office,  from 
Junt  1,  1862,  to  February  1,  1804 — prepared  by  Surgeon  II.  liner,  P. 
A.   C  S.  . 


.2 
o 
o 
q 

a 

ft 

& 
ft 

XI 
o 

a 

M 

Remarks. 

116 

105 

Besides  the  fore- 

Average period  of  recovery. . . 

... 

HU 

going,  there  aro 

t  period  of  recovery .  •  • 

266 

.... 

forty-seven  un- 

41 

— 

decided  cases. 

A  verage  period  of  death 

52 

.... 

<;  reatesl  period  of  death 

IS., 

.... 

1 

— 

Average  amount  of  shortening. 

l.'.l 

Greatest  amount  of  shortening. 

5 

.5 

FRACTURE  IN  UPPER  THIRD. 


395 


Consolidated  Table  of  Amputations  of  the  Thigh,  collated  frdm  records  in 
the  Surgeon- General' a  <\(fiee,  from  June  ],  1802. /<>  February  1,  1SGI — • 
prepared  by  Surgeon  If.  Baer,  P.  A.  C.  S. 


Upper 

Middle 

Lower 

third. 

third. 

third. 

A 

J3 

J 

M 

M 

a 

s 

<u 

s 

o 

ft 

O 

p 

t> 

0 

Circular. 

Primary 

Secondary 


Flap. 

Primary 

Secondary 

Method  not  stated. 

Primary 

Secondary 


Total. 


19 

11 

33 

14 

42 

27 

3 

7 

7 

14 

12 

21 

6 

4 

15 

10 

35 

11 

3 

1 

3 

9 

5 

5 

15 

22 

24 

21 

35 

27 

4 

16 

5 

19 

14 

35 

50 

61 

87 

87 

143 

126 

140 
64 


81 
26 


144 
93 


554 


Besides  the  foregoing,  there  are  ninety-seven  cases  of  amputation 
of  the  thigh  recorded,  but  the  result  not  being  ascertained,  they 
were  excluded  from  this  table.  The  mortality  appears  graver  on  this, 
and  all  other  tables  of  capital  operations,  than  truth  would  warrant, 
inasmuch  as  many  of  these  deaths  occur  within  the  first  few  days  after 
a  battle,  before  the  patient  has  passed  out  of  the  hands  of  his  regimen- 
tal surgeon,  or  while  still  at  the  field  infirmary.  Those  who  do  not 
die.  there  are  sent  off  to  hospitals,  and  some  taken  off  to  private  quar- 
ters by  their  friends,  and  never  again  heard  of — while  all  who  die,  as 
above  stated,  are  recorded.  This  will,  perhaps,  not  only  account  for 
the  large  percentage  of  deaths,  but  also,  in  a  measure,  for  the  want  of 
a  better  correspondence  with  tables  made  under  more  favorable  auspices. 

The  treatment  must  commence  on  the  battle-field 
by  proper  transportation;  the  judicious  removal  of 
fractured  limits  is  as  important  as  an  operation, 
and  any  neglect  in  this  department  will  deprive  the 
wounded  man  of  all  hope  of  retaining  his  limb,  or  of 
having  his  life  saved  We  will  carefully  remove  till 
spicule,  dilating  the  wound,  if  necessary,  by  a  bold 
incision,  to  facilitate  the  thorough  removal  of  all   for- 


396  TREATMENT    IN    THIGH    FRACTURES. 

eign  bodies.  Until  suppuration  is  well  established, 
the  limb  is  kept  in  an  easy  position  and  surrounded 
with  cold  applications.  All  tight,  retentive  ban  dag' 
are  to  be  rejeeted,  as  they  interfere  with  topical  anti- 
phlogistic applications.  Dispense  with  bandages. 
Should  the  case  not  have  been  carefully  examined 
soon  after  its  occurrence, and  every  fragment  of  bone 
removed,  whether  detached  or  not.  a  careful  examina- 
tion for  foreign  bodies  will  be  necessary  on  the  eighth 
or  tenth  day,  when  the  reactionary  stage  has  passed, 
when  all  portions  of  bone  found  in  the  wound  should 
be  removed.  If  not,  as  sequestra,  they  will  become  in- 
corporated in  the  new  osseous  formations,  and  be  the 
cause  of  much  trouble  and  suffering. 

In  all  compound  fractures,  with  much  loss  of  bone, 
it  is  always  injurious  to  attempt  to  obtain  a  limb  of 
equal  length  with  the  sound  one.  It  can  not  be  done, 
and  the  chafing  ami  annoyance  of  splints  and  tight 
bandaging  may  react  very  seriously,  if  not  fatall}', 
upon  the  constitution.  The  first  thing  to  be  attended 
to  is  to  prepare  facilities  for  treating  such  a  fracture. 
ll'  we  are  striving  for  successful  results,  we  must  not 
expect   to  obtain  them  if  a  patient,  with  a  compound 

fracture  of  the  thigh,  is  being  treated  upon  the  ground, 
or  is  lying  upon  a  little  straw.  He  must  have  a  prop- 
er bed  and  a  good  firm  mattress,  prepared  with  a  bed- 
pan hole  for  facilitating  nature's  daily  wants  without 
the  necessity  of  moving  him. 

Upon  this  the  patient  is  placed,  lying  on  his  hack', 
with  the  leg  extended.  Two  long  straps  of  diachylon 
plaster  are  attached  to  the  sides  of  his  leg  from  the 
knee  to  the  ankle  (see  figure  3, plate  24);  they  form  a 
loop  under  the  foot,  and  a  weight  is  swung  from  this 
over  the  foot  of  the  bed.  This  will  be  sufficient  to  tire 
the  muscles  and  make  the  necessary  degree  of  cxten- 


smith's  anterior  splint.  397 

sion;  oi'  the  limb  might  be  loosely  attached  to  a  long 
thigh-splint.  The  tumefaction  roller  is  inadmissible, 
and  strips  of  adhesive  plaster  or  stripe  of  bandage  will 
secure  the  limb  to  the  splint,  and  at  the  same  time 
leave  the  wound  open  for  inspection  and  dressing. 
For  the  first  week  or  ten  days  this  will  be  all  the  ap- 
paratus needed.  As  the  case  advances  and  inflamma- 
tion subsides,  with  a  diminution  of  purulent  discharge 
from  tho  wound,  splints  may  be  more  methodically  ap- 
plied by  using  long  inner  and  outer  splints  of  light 
board,  well  padded  with  loose  cotton,  and  secured  in 
position  by  hands  of  adhesive  plaster  or  with  tapes. 
The  extending  hands  are  made  by  adhesive  strips,  at- 
tached to  the  sides  of  the  leg  and  carried  under  the 
foot,  where  they  are  secured  to  the  end  of  the  splint. 
Allow  the  ends  of  the  bones  to  fill  up  the  void  made 
by  the  extraction*  of  the  spicule,  as  this  hastens  con- 
solidation. 

A  better  method  of  treating  fractures  of  the  thigh 
is  in  the  use  of  Smith's  anterior  splint,  or  Mayor's 
posterior  wire  splint  (see  plate  25),  by  which  the  limb 
is. suspended.  Smith's  anterior  splint  is  formed  of  a 
strong  iron  wire  (three-sixteenths  of  an  inch)  bent 
in  the  form  of  a  parallelogram,  as  long  as  the  limb,  and 
five  inches  wide.  Cross-pieces  of  the  iron  prevent  the 
sides  from  collapsing,  and  are  also  used  for  suspending 
the  limb.  This  wire  splint  is  placed  upgn  the  anterior 
surface  of  the  limb.  While  traction  is  being  made 
npon  the  foot  by  an  assistant,  which  removes  all 
shortening,  tho  splint  is  secured  by  enveloping  the  en- 
tire limb  in  a  roll  of  bandage,  omitting  the  banda 
the  points  where  the  ball    has  perforated.      "When  this 

Bandage  is  nicely  adjusted  it  should  be  covered  with  a 

thick-  sol  ut  ion  of  Starch,  which  wid  glue  all  of  the  hands 
together,  and  form  a  mould  for  the  limb,  which  sup- 


398  mayor's  posterior  splint. 

ports  it  equally  throughoul  its  entire  extent,  and 
gives  great  relief.  When  properly  applied,  the  patient 
should  be  altogether  free  from  pain.     The  limb  is  then 

suspended  two  or  three  inches  above  tho  bed,  by 
passing  cords  from  the  upper  and  lower  cross-wires 
of  the  splint,  all  of  which,  uniting  in  a  single  cord,  is 
attached  to  the  ceiling  or  top  of  the  bedstead.  With 
the  limh  thus  suspended,  the  patient  may  move  about 
in  the  bed  at  pleasure,  without  tear  of  disturbing  the 
adjustment  or  giving  himself  pain.  As  the  roll  of 
bandage  has  been  omitted  at  tho  site  of  the  -wound, 
local  applications  can  be  daily  made  and  the  parts 
duly  inspected.  This  has  become  the  favorite  method 
of  treating  compound  fracture  of  the  lower  extremity 
in  the  Confederate  service;  although  the  anterior 
splint  is  better  adapted  to  compound  fractures  of  the 
leg,  where  it  offers  every  desirable  facility  for  success- 
ful treatment.  The  very  great  advantage  which  i4 
possesses  is  in  allowing  the  patient  to  shift  his  position 
without  moving  the  hones  at  the  seat  of  fracture,  and 
this  assists  in  preventing  bed-sores.  It  also  uses  the 
body  for  counter-extension,  and  in  this  way  overcomes 
muscular  contraction  and  excessive  shortening.  Tho 
greatest  objection  to  its  uso  is  that,  as  the  splint  re- 
quires nice  adjustment,  careless  manipulators  find  in 
it  a  very  troublcsomo  appliance,  with  constantly  shitt- 
ing bandages„badly  supporting  the  limb,  and  inducing 
the  bagging  of  pus.  When  carefully  applied,  it  always 
gives  satisfaction. 

Mayor's  posterior  splint,  although  a  much  older 
apparatuses  still  used  with  great  advantage  in  com- 
pound fractures  of  the  lower  extremity.  The  principle 
of  action  is  the  same,  viz:  suspending  the  limb  so  astjjj 
ensure  rest  of  the  broken  ends;  while,  at  the  same 
time,  the  patient  is  permitted  to  shift  his  position,  and 


TREATMENT    OF    FRACTURED   THIGH.  399 

avoid  bed-soros  from  continued  pressure!  In  Mayor's 
posterior  splint  tbe  injured  limb  receives  a  firm,  regu- 
hu*  support  from  tbe  unyielding  splint.  Smith's  splint, 
on  the  contrary,  supports  the  limb  only  by  tbe  band- 
age, which,  in  successive  turns,  passes  around  the  leg 
and  the  splint.  The  comfort  of  the  apparatus  will  de- 
pend altogether  upon  the  care  and  regularity  with 
which  this  bandage  is  applied.  If  some  bands  are 
drawn  tighter  than  otbcrs,  instead  of  presenting  a 
smooth  plane,  moulded  upon  the  limb  for  its  perfect 
and  painless  support,  the  irregular  adjustment  will 
suspend  the  sensitive  extremity  by  a  few  cords  or 
tight  bands,  which,  by  their  irregular  support,  can  not 
but  produce  much  suffering.  In  the  hands  of  a  nice 
manipulator,  Smith's  anterior  splint  is  the  perfection 
of  a  fracture  apparatus;  for  general  use,  Mayor's  pos- 
terior splint  is  decidedly  preferable.  Another  decided 
advantage  which  Mayor's  splint  possesses  is,  that  as 
the  limb  is  only  secured  at  a  few  points,  nearly  the 
entire  extremity  is  exposed  for*  inspection  or  the  ap- 
plication of  remedies.     (See  plate  25.) 

With  tbe  exception  of  the  mechanical  appliances  for 
the  broken  bone,  the  case  is  treated  as  for  a  long-con- 
tinued suppurating  wound,  by  avoiding,  in  all  cases. 
depiction,  and  by  giving  liberal  diet.  Man}*  of  these 
Cases  will  die;  but  if  we  have  facilities  in  a  well-venti- 
lated and  well-organized  hospital,  we  will  bave  tho 
satisfaction  of  saving  nearly  half  of  the  patients  sub- 
mitted to  our  care.  Of  221  cases  of  compound  fract- 
ure of  the  femur  reported  by  Confederate  surgeons  us 
treated  in  military  hospitals  from  June  1,  1862,  to 
February  1.  l^m,  116  wen:  successful;  while  of  554 
thighs  amputated,  280  recovered. 

In  fractures  of  the  middle  and  lower  third  of  the 
thigh,  not    implicating    the  knee-joint,   the   question 


400  TREATMENT   OF    FRACTURED    THIGH. 

will  again  recur,  what  course  is  to  bo  pursued  with 
such  1  These  arc  still  very  serious  cases,  and  are 
classed  with  those  of  the  upper  third.  Where  attempts 
are  made  to  save  them,  as  recommended  by  Guthrie, 
the  fatality  will  not  be  very  dissimilar  to  fractures 
nearer  the  trunk,  and  the  successes  will  depend  upon 
the  state  of  health  of  the  sufferer  and  the  conveniences 
for  treatment. 

There  are  cases  which  often  appear  so  trivial — only 
a  small  bullet-hole  leading  to  the  crushed  bone — that 
it  seems  barbarous  surgery  to  condemn  the  limb  with- 
out an  attempt  at  saving  it.  The  young  military  Bur- 
geon expects  much  from  conservative  surgery  in  such 
cases.  We  are  informed  by  the  experienced  that  this 
Striving  after  conservatism  is  the  main  cause  of  the 
heavy  mortality. 

Surgeons  from  civil  life  are  not  prepared  to  believe 
bow  dangerous  compound  fractures  of  the  thigh  are  in 
military  surgery,  until  the  unwelcome  truth  is  forced 
upon  them  by  an  ever-recurring  experience  that  many 
lives  are  sacrificed  to  attempts  at  saving  these  broken 
limbs.  In  civil  surgery,  or  with  every  facility  in  mili- 
tary hospitals,  wo  should  attempt  to  save  the  limb — it 
is  the  proper  course  to  pursue — but  on  the  battle-field, 
with  the  deteriorated  material  upon  which  we  an- 
operating,  and  the  poisoned  atmosphere  of  the  wards 
into  which  the  patient  is  to  be  carried,  and  the  rough 
transportation  to  which  he  must  be  submitted,  it  is 
often  a  fatal  error.  Military  surgeons  are  often  forced 
to  abandon  their  conservative  intentions  to  expedi- 
ency. It  is  for  such  cases  that  primary  amputation 
offers  the  best  chances  for  life.  In  rejecting  amputa- 
tions  we  lose  more  lives  than  we  save  limbs.  As  a 
rule,  amputations  are  less  hazardous  the  greater  dis- 
tance we  operate  from  the  trunk;  and  the  reason  why 


TREATMENT  OF  FRACTURED  THIGH.       401 

amputations  are  usually  urged  for  compound  fractures 
of  the  lower  and  not  upper  portions  of  the  femur  is, 
that  the  chances  being  similar  without  it,  amputa- 
tions are  much  less  fatal  in  the  lower  than  in  the 
upper  half  of  the  thigh. 

With  the  light  of  recent  experience,  and  the  advan- 
tages found  in  removing  all  fragments  which,  as  thorns 
in  the  flesh,  are  the  direct  cause  of  much  of  the  suffer- 
ing, suppuration,  and  fatal  accompanying  symptoms, 
the  urgency  for  amputation  is  not  so  great  as  in 
former  wars,  and  many  lives  and  limbs  can  now  be 
saved  by  adopting  this  rule  of  practice. 

Surgeons  in  the  Crimea  often  had  cause  to  regret 
attempts  at  saving  fractured  thighs,  but  never  regret- 
ted an  early  amputation.  The  improvements  in  more 
recent  practice  warrant  us  in  adopting  a  more  conserv- 
ative surgery. 

Resection,  or  the  cutting  off  of  the  sharp  spiculated 
ends  from  the  shaft  of  the  femur,  for  a  compound  fract- 
ure of  the  bone,  has  been  frequently  recommended, 
and  often  practised  j  but  the  experience  of  lattor  years 
discourages  its  pei-formance,  as  the  operation  is  as 
serious  as  the  condition  for  which  the  remedy  is  used. 
When  the  splinters  of  bone  are  removed,  there  is 
considerable  space  for  the  play  of  the  rough  remaining 
edges,  which,  therefore,  give  but  little  trouble. 

Should  we  attempt  to  save  a  fractured  thigh  in  its 
lower  third,  which  we  should  do  in  many  instances, 
where  the  soft  parts  are  not  extensively  torn,  or  im- 
portant vessels  and  nerves  injured,  the  first  and  essen- 
tial step  to  success  consists  in  a  careful  exploration 
of  tho  wound,  and  the  removal  of  all  fragments  of  the 
bone  crushed  by  the  ball,  whether  these  fragments  be  loose 
or  not.  Even  should  the  shaft  for  three  or  four  inches 
be  found  broken  up,  remove  all  of  it.  It  is  these 
lln 


IQ2  TREATMENT    OF    FRACTURED   THIGH. 

fragments  which  cause  the  irritation  and  profuse  sup- 
puration which,  in  most  instances,  destroy  life  in  gun- 
shot fractures.  The}'  all  have  their  nutrient  vessels 
so  injured  that  they  rarely  consolidate;  they  nearly 
always  die;  and  it  is  in  attempts  to  throw  off  these 
that  nature  exhausts  herself. 

Should  the  orifico  not  he  sufficiently  largo  to  permit 
the  thorough  cleansing  of  the  wound,  enlarge  the 
opening.  It  would  be  woll  should  this  operation  bo 
performed  at  tho  first  dressing.  If  unavoidably  de- 
ferred until  tho  reactionary  stage  has  passed,  it  would 
be  of  decided  advantage  to  perform  it  at  any  time 
after  the  first  week.  Tho  earlier  it  is  accomplished  the 
sooner  irritation  is  allayed,  and  tho  more  rapidly  a 
cure  is  effected.  The  after-treatment  consists  in  keep- 
ing the  leg  extended  upon  the  bed,  and  the  wound 
under  the  influence  of  cold  water  dressing.  As  short- 
ening must  occur  from  the  loss  of  bone,  putting  the 
leg  immediately. in  retentive  apparatus,  so  as  to  keep 
it  to  its  former  length,  will  be  a  causo  of  irritation 
which  would  bo  injurious,  and  the  free  discharge  of 
pus  would  so  soil  tho  dressing  as  to  necessitate  its  re- 
application  daily,  which  would  be  very  trying  to  the 
patient. 

For  tho  first  fortnight,  succossful  results  are  best 
promoted  by  keeping  tho  limb  in  an  easy  position, 
with  a  wet  cloth  over  and  around  the  wound,  which 
can  bo  frequently  renewed  without  disturbing  the  leg. 
When  tho  period  of  excitement  has  passed,  the  limb 
may  be  then  kept  quiet  or  stiffened,  by  using  cither  a 
straight  splint  with  the  starch  bandage,  leaving  an 
opening  corresponding  with  tho  Avound,  or  tho  log 
can  be  comfortably  secured  upon  an  inclined  plane,  as 
seen  in  plate  24,  figure  5,  which  represents  a  very 
convenient  form  of  apparatus.     Tho  treatment  in  all 


REMOVE   ALL   FRAGMENTS    OF   BONE.  403 

of  these  cases  will  be  very  tedious — the  average  of 
cure,  as  collected  from  reports  to  the  Surgeon-General, 
being  104  days  ;  the  longest  period  being  255,  and  the 
most  speedy  cure  41  days.  This,  however,  we  may 
lay  down  as  a  rule :  that  recovery  is  expedited  for 
every  fragment  of  bone  that  we  remove,  the  most 
satisfactory  results  being  connected  with  their  early 
and  thorough  removal. 

The  following  case,  from  the  Soldiers'  Relief  Hospi- 
tal, Charleston,  under  Surgeon  W.  H.  Huger,  will 
exhibit  the  advantages  of  the  course  which  has  been 
so  strongly  recommended  above.  Private  R.  A. 
Howell,  Company  H,  21st  South  Carolina  regiment, 
was  wounded  by  a  minie  ball  at  an  assault  upon 
Fort  Wagner,  10th  of  July,  1863.  lie  was  taken 
prisoner  by  tbe  Federalists,  and  after  two  weeks 
exchanged,  when  he  entered  the  hospital.  The  ball 
had  traversed  the  limb  antero- posteriorly,  at  a 
junction  of  the  middle  and  upper  third,  crushing  the 
femur  for  a  distance  of  from  four  to  five  inches. 
When  received,  the  suppuration  was  excessive  and  ex- 
hausting. Large  pouches  containing  pus  bagged  in  his 
thigh,  and  hectic  fever,  with  its  accompanying  emacia- 
tion, had  already  made  marked  inroads  upon  him. 
When  motion  was  imparted  to  the  thigh,  the  broken 
fragments  could  be  moved  about  so  freely  as  to  impart 
the  sensation  of  foreign  bodies  in  a  bag.  The  finger 
passed  into  the  wound  detected  also  denuded  ami 
movable  fragments.  Upon  consultation,  it  was  de- 
termined to  lay  open  the  limb  and  remove  all  frag- 
ments, as  the  only  course  offering  any  prospects  of 
saving  life,  as  hisdaily  increasing  debility  admonished 
us  that  he  could  not  hold  out  much  longer  in  his 
present    condition;    and    the   wound   was  so  near  the 

trunk,  and  large  abscesses  had  so  dissected  the  soft 


404  TREATMENT    OF    FRACTURED   THIOH 

parts,  as  to  render  an  amputation  Dear  the  trochanters 
extremely  hazardous.  Under  chloroform  the  opera- 
tion was  very  protracted.  After  removing  all  the 
loose  and  dead  portions  of  bono,  it  was  found  that  large 
masses  firmly  connected  to  the  sofl  parts  by  a  thick- 
ened periosteum,  and  still  firmly  adherent  by  an  inter- 
mediary deposit  of  new  bone,  were  perfectly  denuded 
upon  their  free  surface,  and  when  removed  showed 
dearly  the  process  of  death  in  Buch  fragments,  and 
their  incarceration  by  new  osseous  formations.  All 
such  fragments,  however  firmly  connected  with  the 
soft  parts,  were  taken  away,  comprising  very  nearly 
five  inches  of  the  shaft  of  the  femur.  The  patient  ral- 
lied from  the  operation,  and  an  improvement  in  his 
case  commenced  from  that  moment.  Under  liberal  and 
stimulating  diet  the  suppuration  gradually  diminished, 
and  he  became  cheerful,  with  good  appetite,  lie  was 
furloughcd  on  November  :; — the  wound  baving  com- 
pletely healed,  and  perfect  osseous  union  effected,  with, 
however,  a  slight  angular  deformity  at  the  site-  of 
union — it  having  been  found  impossible  to  avoid  the 
displacement  of  the  upper  fragment,  as  no  devised 
splints  seemed  to  meet  the  requirements  of  the  ease. 
Had  this  case  not  been  operated  upon,  there  was  every 

prospect  of  a   speedy  death  ;   and  in  similar  fractures. 

where  life  had  been  spared, necrosis,  suppuration,  and 
Buffering  remain  permanent  companions  of  the 
wounded. 

In  compound  fractures  of  the  lower  portion  of  the 
thigh,  the  inclined  plane  is  found  the  mo8l  convenient; 
apparatus,  as  it  oilers  the  most  comfortable  position 
to  the  patient,  hut   has  the  disadvantage  of  promoting 

the  burrowing  of  pus,  which,  in  working  its  way  down. 
the  limb,  may  dissect  passages  for  itself  as  far  as  the 
buttock,  and,  by  its   multiplied   openings,  unless  cor- 


KNEE-JOINT    INJURIES.  405 

rected  by  a  firmly-applied  roll  of  bandage,  causes 
much  annoyance,  as  well  as  destruction  to  bones  and 
muscles. 

Mayor's  patent  wire  splint,  which  combines  the  ad- 
vantages of  the  inclined  plane,  will  be  found  a  very 
comfortable  mode  of  dressing. 

The  anterior  wire  splint  of  Smith  is  found  also 
useful  in  these  fractures,  although  a  straight,  long 
splint,  so  attached  as  to  keep  the  broken  ends  of  the 
bone  quiet,  and  so  stiffen  the  limb  that  it  can  be  lifted 
without  pain,  forms  a  most  serviceable  apparatus*. 
Whatever  be  the  appliance,  the  wounds  must,  be  allowed 
free  vent  for  their  discharges. 

When  the  knee-joint  is  implicated  in  a  shot  wound, 
or  Cut  open  by  a  shell,  with  injury  to  the  head  of  the 
tibia  or  femur,  experience  has  shown  that,  however 
trivial  the  wound  may  appear,  if  the  synovial  sac  be 
entered,  and  air  be  admitted,  or  a  foreign  body  lie 
within  the  joint,  violent  synovitis,  with  great  pain> 
swelling,  and  heat,  and  with  excessive  inflammatory 
lever,  will  come  on  after  twenty-four  or  thirty-six 
hours.  Should  the  patient  survive  the  inflammatory 
stage,  erysipelas,  pyaemia,  or  hectic  will  ultimately 
destroy  life;  and  although,  on  the  other  hand,  the, 
effusions  may  be  absorbed,  and  an  anchylosed  but  use- 
ful limb  saved,  it  is  a  very  rare  occurrence.  If  the 
soft  parts  are  nut  much  lacerated,  or  the  blood-vessels 
and  nerves  behind  the  joint  injured,  such  eases  are 
well  adapted  for  resection,  and  excellent  results  are 
obtained  in  practice. 

A  straight  or  elliptical  incision  over  tin-  anterior 
portion  of  the  joint,  across  its  entire  diameter,  will  ex- 
DOSe  the  interior  and  enable  the  surgeon  (o  remove 
the  foreign  bodies,  whatever  they  may  he,  and  with 
them   the    head   of  the   injured  hones.      The   section  of 


!<"'>  KNEE-JOINT    INJURIES. 

the  bones  should  be  made  in  such  a  way  that  the  sur- 
u  ill  adapt  themselves  to  each  other — usually  the 
patella  is  removed.  When  the  external  wound  is 
!  by  SO.tures,  union  by  the  first  intention  may,  to 
a  certain  extent,  be  obtained.  In  the  Buccessful  oases 
the  bones  eventually  heroine  firmly  united,  and,  with 
an  anchylosed  joint,  the  patient  retains  a  useful  limb. 

After  the  resection,  a  long  splint  upon  the  hack  of 
the  [eg,  reaching  from  the  buttock  to  the  heel,  is  all 
the  apparatus  required,  while  cold  water  dressings 
alone  are  applied  around  the  joint.  In  cases  of  resec- 
tion the  surgeon  must  not  expect  quick  union  in  the 
wound,  as  that  docs  not  often  occur  in  military  sur- 
gery. A  tedious  suppuration,  the  formation  of  numer- 
ous abscesses,  and  often  the  exfoliation  of  portions  a£ 
bone,  is  the  rule,  requiring  care  ami  judicious  manage- 
ment to  obtain  a  final  success  —  many  of  those  operated 
Upon  being  lost  by  the  action  of  those  deleterious 
causes  winch  affect  injuriously  all  wounds  in  military 
hospitals. 

When  attempts  are  made  to  save  the  limb  in  what 
we  suppose  to  be  a  trivial  or  doubtful  case  of  knee- 
joint  injury,  we  should  follow  the  routine  of  the  anti- 
phlogistic treatment.  Jn  a  single  puncture  of  the  cap- 
8U  le,  even  when  synovia  has  escaped,  the  orifice  may  heal 
by  quick  union.  When  local  inflammation  ensues,  and 
runs  Such  an  acute  course  that  the  \'wc  application  of 
leeches — twenty  to  forty  to  a  limb — the  continued  use 
of  cold  water  or  ice  dressing,  with  the  general  treat- 
ment of  opium  and  small  doses  of  antimony,  etc., 
does  not  quell  the  inflammation,  and  w  e  are  led  to  inter 
that  pus  has  formed  within  the  joint,  the  articulation 
shouldbe  (<ir</<  ly  opt  /<<</.  .nu/  the  joint  thoroughly  cleansed, 
whether  we  resect  the  heads  of  the  hones  or  not. 
There  is  no  longer  injury  from  the  admission  of  air, 


COMPOUND   FRACTURE   OP   THIGH.  407 

while  there  is  serious  fear  of  destruction  of  the  carti- 
lages should  the  collection  of  pus  be  retained.  This 
free  opening  of  the  articulation  may,  in  some  cases, 
obviate  the  necessity  for  secondary  resections  and  am- 
putation, as  excellent  results  have  been  obtained  by 
this  apparently  bold  surgery — the  patient  saving  his 
life  and  limb.  The  effect  of  this  incision  into  the  joint, 
in  allaying  the  general  irritation,  is  marked. 

As  a  rule,  gunshot  wounds  of  the  knee-joint  are  so 
fatal  that  the  experience  of  military  surgeons  confirm 
the  necessity  for  amputating  all  such  eases.  In  the 
reports  from  many  military  hospitals  every  case  of  per- 
forating wound  of  the  knee,  in  which  no  operation  was 
performed,  proved  fatal;  and  of  all  tho  cases  reported 
from  the  army  to  the  Surgeon-General's  office,  wc  find 
but  50  successful  cases  out  of  103  cases  treated. 

Tho  course  which  will  be  pursued  with  a  fracture  of 
the  bones  of  the  leg  must  depend  upon  the  extent  of 
injury  to  the  soft  parts,  and  also  the  facilities  at  hand 
for  treating  fractures.  Our  main  object  is  always  to 
save  life,  and,  if  possible,  the  limb  also;  but  in  our 
too-grasping  disposition  wc  mast  be  very  guarded  how 
we  jeopard  the  one  to  save  the  other.  It  is  in  this  re- 
spect that  military  surgery  is  so  very  different  from 
civil  practice.  We  are  continually  compelled  to  sacri- 
fice limbs  to  expediency,  when,  under  more  favorable 
conditions,  wTe  would  not  hesitate  to  practice  conserva- 
tive surgery.  To  introduce  a  single  example:  where 
a  long  and  tedious  transportation  becomes  necessary 
after  a  battle,  it  would  be  expedient  to  amputate 
much  more  freely  than  we  would  do  were  there  hos- 
pitals in  the  immediate  neighborhood  of  the  battle-field 
where  the  wounded  could  be  treated.  How,  for  in- 
stance, COUld  we  transport,  with  any  chance  of  BUCC6SS, 
a  resected  joint,  such  as  the  shoulder,  or  a  gunshot- 


408  INJURIES   TO   ANKLE-JOINT. 

fractured  thigh  or  leg  ?  Under  such  circumstances 
an  amputation  would  give  the  patient  a  much  better 
chance  for  life,  which  should  always  bo  the  main 
object. 

When  facilities  offer  for  attempting  the  preservation 
of  a  fractured  leg,  the  same  precautions  are  taken  as 
in  other  fractures,  for  removing  immediately  all  loose 
or  very  movable  fragments  of  bone.  The  limb  is 
placed  in  a  fracture-box,  or  upon  the  double  inclined 
plane,  and  by  the  constant  application  of  cold  water, 
while  we  use  those  remedies  already  suggested  for 
kc  oping  down  an  excessive  reaction,  we  watch  the  pro? 
gress  of  the  case,  and  meet  the  various  complications 
as  they  arise,  by  the  rules  of  practice  which  have  been 
already  frequently  discussed. 

It  is  in  this  class  of  fractures  that  Smith's  anterior 
splint,  or  Mayor's  posterior  splint,  will  exhibit  a  long 
list  of  splendid  triumphs — cures  without  doformity,  and 
with  the  smallest  amount  of  shortening ;  a  painless 
treatment,  allowing  the  patient  to  move  about  at  will, 
and  even  leave  his  bed  the  first  week  after  the  recep- 
tion of  injury.  Should  mortification  appear  in  the 
wound  a  few  days  after  the  injury,  we  will  find  in 
early  amputation  the  only  moans  of  safety. 

Resections  of  the  ankle-joint  have  not  been  follow- 
ed by  that  success  which  has  characterized  operations 
upon  the  larger  joints,  especially  the  knee  and  the 
elbow.  It  is  recommended  as  a  conservative  meas- 
ure, but  is  seldom  practised.  When  gunshot  injuries 
occur  about  the  ankle,  crushing  the  bones,  excision 
offers  but  a  meagre  resource.  Mortification  often 
follows  such  injuries,  and  amputation  holds  out  strong- 
er inducements  for  immediate  ami  subsequent  benefit. 

Gunshot  wounds  of  the  foot,  with  extensive  crush- 
ing of  the   tarsal   and   metatarsal   bones,  frequently 


_^.    .  NECESSITY    FOR   AMPUTATIONS.  409 

require  amputation  in  these  joints.  In  ordinary  per- 
forations of  the  foot  by  balls,  even  with  injury  to  the 
bone,  a  cui-e  is  eventually  effected ;  but  such  cases  are 
always  tedious,  months  elapsing  before  the  patient 
can  support  his  body  upon  the  foot,  and  much  pain 
attends  pressure.  The  treatment  differs  in  no  respect 
from  that  laid  down  in  general  rules.  Removal  of 
osseous  fragments  and  cold  water  dressings  comprise 
the  treatment.  When  the  foot  is  so  mangled  that  anv 
amputation  is  considered  best  for  the  patient,  the 
foot  can  be  removed  at  airy  of  its  articulations. 

We  have  often  referred  to  the  fact  that  amputations 
will  ever  be  a  necessit}*  in  military  surgery ;  and,  ac- 
cording to  McLeod,  had  they  been  more  freely  practised 
in  the  Crimea,  a  large  number  of  lives  would  have 
been  saved. 

Among  a  certain  class  of  surgeons,  on  the  contrary, 
however,  amputations  have  often  been  performed  when 
limbs  could  have  been  saved,  and  the  amputating  knifo 
has  been  often  brandished,  by  inexperienced  surgeons, 
over  simple  flesh  wounds.  In  the  beginning  of  the  war 
the  desire  for  operating  was  so  great  among  the  large 
number  of  medical  officers  recently  from  the  schools, 
and  who  were  for  the  first  time  in  a  position  to  indulge 
this  extravagant  propensity,  that  the  limbs  of  soldiers 
were  in  as  much  danger  from  the  ardor  of  young  sur- 
geons as  from  the  missiles  of  the  enemy. 

It  was  for  that  reason  that,  in  the  distribution  of  la- 
bor in  the  field  infirmaries,  it  was  recommended  that 
the  surgeon  who  had  the  greatest  experience,  and  upon 
whose  judgment  most  reliance  could  bo  placed,  should 
officiate  as  examiner,  and  his  decision  be  carried  out  by 
those  who  may  possess  a  greater  facility  or  desire  for 
the  operative  manual. 

As  a  general  rule,  the  following  conditions  necessi- 
Ii 


Jin  WHEN    TO   AMPUTATE.  ..  ^._ 

t  at  o  the  I08S  of  a  limli,  viz:  When  an  entire  limb  is 
carried  off  by  a  cannon-ball,  leaving  a  ragged  stump, 
or  when  a  limb  is  literally  crushed  up,  although  still 
attached  t<>  the  body,  it  will  be  necessary  to  amputate 
to  form  a  good  si  ump ;  also,  if  the  principal  vessels  and 
nerves  are  extensively  torn,  even  without  injury  to 
the  hone;  or  if  the  soft  parts  are  much  lacerated;  or 
in  cases  of  extensive  destruction  of  the  skin — as  such 
'cases  offer  very  tedious  cures,  if  cicatrization  is  ever 
obtained.  Again,  in  severe  compound  fractures,  and 
often  in  apparently  simple  compound  fractures,  where 
experience  teaches  us  that,  although  the  wound  may 
appear  trilling  to-day,  in  attempting  to  save  it  we  will 
sacrifice  lite  a  lew  days  hence.  Amputation  is  com- 
pulsory when  mortification  of  the  limb  rapidly  follows 
upon  an  injury;  also  when,  in  compound  fractures  or 
perforated  joints,  the  profuse  discharge  or  the  con- 
tinued irritation  threatens  a  fatal  issue;  again,  where 
joints  are  crushed,  and  where  resections  are  not  ad- 
missible; or  where  a  fracture  of  the  shaft  of  a  bono 
extends  into  a  joint  ;  also  in  cases  where  secondary 
hemorrhage  can  not  he  controlled  by  the  ligature,  or 
by  any  other  hemastatic.  Knowing  that  in  such  < 
sooner  or  later,  the  life  will  be  jeoparded,  we  must,  an- 
ticipate these  troubles  by  amputation. 

.Military  surgeons  have  long  made  the  important 
division  of  amputations  into  primary  and  secondary — 
a  division  of  great  practical  importance,  and  which 
forces  itself  upon  our  notice  by  the  relative  mortality 
following  the  two  operations.  A  mputations  for  direct 
injuiy,  which  are  performed  after  the  shock  has  passed 
off,  but  before  inflammatory  symptoms  make  their 
appearance,  are  styled  primary;  those  required  for 
cases  of  mortification,  profuse  suppuration,  secondary 
hemorrhage,  or  for  necrosis,  are  called  seeondaiy  or 


TIME    FOR   AMPUTATIONS.  411 

mediate,  and  comprise  all  amputations  performed  after 
the  first  twenty-four  or  forty-eight  hours,  when  reac- 
tion has  set  in.  A  third  division  of  intermediary 
amputation  is  a  subdivision  of  the  secondary,  and  re- 
fers to  cases  amputated  from  the  second  to  sixth  day. 
An  examination  of  the  following  table  will  show, 
satisfactorily,  the  advantages  of  operating  early. 


412 


TI.MK    FOR    AMPUTATIONS. 


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SUCCESS    OP   AMPUTATIONS. 


413 


•  The  very  large  number  of  results  not  stated  is  ac- 
counted for  by  those  amputated  upon  the  field,  some  of 
whom  fall  into  the  enemy's  hands;  others  are  sent  to 
private  hospitals,  or  arc  treated  in  private  families  by 
physicians  who  are  not  in  the  army,  and  who,  there- 
fore, make  no  report  of  the  case.  While  in  many  cases 
only  the  number  of  operations  are  reported,  but  as  the 
cases  are  still  under  treatment  the  final  results  can  not 
be  given.  If  we  be  permitted  to  divide  the  list  of 
unknown  results  proportionately  between  the  cures 
and  deaths,  which  would  give  us  even  a  larger  propor- 
tion of  deaths  than  occur,  as  the  cases  scattered  through 
the  country  usually  recover,  it  will  exhibit  the  most 
successful  army  practice  of  modern  times. 

I  here  insert  a  comparative  table  of  amputations 
from  recent  wars,  showing  the  result  of  practice 
among  those  whom  we  are  accustomed  to  consider  the 
best  surgeons,  and  to  whom  we  are  indebted  for  most 
of  our  medical  and  surgical  knowledge.  When  it  is 
remembered  that  the  French  and  English  include  all 
OaBes  of  minor  amputations,  viz:  of  fingers  and  toes, 
in  their  report,  while  the  Confederate  report  for  one 
of  the  three  years  of  the  war  comprises  capital  ampu- 
tations only,  our  great  success  will  be  appreciated. 

COMPAKATIVE  REPORT  OF  ARMY  AMPUTATIONS. 


English  in  Crimea.. 
French  in  Crimea. . 

(''•ii  li-ilcrntc  army. , 


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1,464! 

8,181 

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37     . 

Remarks. 


Includes  all  minor  am 
tut  ions  of  fingers,  toes,  etc 


apu- 


*  Capital  amputations  alone   performed  iu   Confederate    arniv   from 
June  1,  1S62,  to   February  1,  1864. 


II I 


'I  [ME    FOB     AMITTATlliNS. 


The  relative  success  will  be  more  conspicuously 
brought  out  by  comparing  the  results  in  any  one 
amputation,  viz  :  that  of  i  he  thigh,  which  is  considered 
by  far  the  most  fatal  in  military  Burgery. 

COMPARATIVE  .STATISTICS  OF  AMPUTATION  OF  THIGH. 


Crimean  war 

Confederate  war,  June  1,  1802,  to  Feb.  1, 
1864 


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1,664 

123 

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256 

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a,  a 


I  ii  amputations  of  superior  half  of  thigh  the  Crimean 
mortality  was  ninety-four  in  every  one  hundred  oper- 
ated on,  while  our  reports  for  the  year  L863  give  a 
mortality  of  fifty-seven  in  every  one  hundred,  or  the 
recovery  of  nearly  half  of  our  cases. 

The  experience  of  every  battle-field  shows  thai  the 
mortality  following  the  amputation  of  limbs  which,  re- 
quire immediate  operation  is  always  less  than  those 
performed  some  days  after  the  infliction  of  the  wound 
— although   the   milder  oases  were  those  retained,  and 

the  most  severe  those  selected  for  immediate  opera* 
tion.  As  all  military  surgeons  recognize  the  propriety 
of  amputating  condemned  limbs  within  twenty-four  or 
thirty-six  hours  after  the  injury,  before  inflammatory 
reaction  has  sel  in.  the  aubjeel  requires  no  discussion. 
The  rule  in  military  surgery  is  absolute,  viz  :  That  the 
amputating  knife  should  immediately  follow  the  condemna- 
tion of  the  limb.  These  are  operations  for  the  battle- 
field, and  should  he  performed  at  the  tield  infirmary. 
When  this  golden  opportunity,  before  reaction,  is  lost, 
it  can  never  be  compensated  for. 

The  rule  in  performing  primary  amputations  is  to 


MORTIFICATION    OP    STUMP.  415 

operate  as  far  as  possible  from  the  trunk,  as  every 
inch  diminishes  the  risk  to  life.  This  rule  is  so  general, 
that  when  an  amputation  can  be  performed  at  a  joint, 
never  amputate  higher  up.  The  only  exception  made 
to  this  rule  is  in  the  knee-joint  disarticulation,  which, 
on  account  of  its  large  synovial  surface  and  inflamma- 
tion which  follows,  gives  very  bad  results.  In  examin- 
ing our  statistics  for  disarticulations,  it  will  be  found 
that  of  eleven  cases  of  amputation  through  the  knee- 
joint  nine  died;  while  of  sixty-seven  amputations  in 
the  lower  third  of  thigh,  forty-three  died. 

In  secondary  amputations  it  may  not  be  expedient 
to  follow  this  rule;  necessitj',  or  the  desire  to  save  life, 
which  is  always  paramount,  may  compel  us  to  ampu- 
tate at  a  distance  from  the  injury,  as  in  cases  of  mor- 
tification. If  the  rules  for  primary  amputation  be 
followed,  viz:  of  removing,  at  once,  all  limbs  in  which 
the  blood-vessels  and  nerves  are  extensively  injured  in 
connection  with  the  crushing  of  the  bones,  there  would 
be  seldom  gangrene  to  require  a  secondary  amputation. 

When  mortification  attacks  a  limb,  it  will  be  known 
by  change  of  color  in  the  skin.  When  it  occurs  in  the 
tag,  which  is  its  common  seat,  the  foot  changes  from 
the  natural  flesh  color  to  a  tallowy  or  mottled  white; 
the  tissues  in  a  measure  liquefy,  are  cold,  and  become 
offensive — breaking  up  into  more  or  less  extended 
sloughs,  saturated  with  an  ichorous  fluid.  This  gan- 
grenous condition  may  stop  at  the  ankle,  either  above 
or  below  it,  depending  upon  the  seat  of  injury;  or  it 
may  creep  up  to  the  knee,  where  it  equally  shows  a 
disposition  to  limit  its  extension.  When  the  ankle 
limits  the  mortification, we  amputate  below  the  knee; 
when  otherwise,  above  it.  These  cases  are  usually 
unsatisfactory,  as  a  general  poisoning  is  soon  effected, 
and  the  Stump,  wherever  made,  is  attacked  in  a  few 


416  *     MODI  RATING. 

days,  sometimes  in  a  few  hours,  as  if  by  a  continua- 
tion of  the  same  gangrene. 

In  mortification  of  the  stump,  upon  tho  upper  por- 
tion of  a  limb,  a  second  amputation  is  inadmissible. 

By  the  local  use  of  pure  nitric  acid  to  the  mortified 
surface,  or  the  concentrated  Labarraque's  chloride  of 
soda,  or  pyroligneous  acid,  we  strive  to  limit  the  ex- 
tent of  the  slough;  while,  with  carbonate  of  ammo* 

nia,  quinine,  brandy,  and  strong  food,  we  support  the 
system  until  some  improvement  makes  its  appear- 
ance in  the  stum]!.  When  all  the  sloughs  have  been 
eliminated,  and  the  stump  has  commenced  to  cica- 
trize, let  time  remodel  the  old  amputation. 

Having  condemned  a  limb,  we  should  wait  until  the 
nervous  shock — from  which  most  of  the  wounded  suf- 
fer— subsides,  and  then  give  chloroform.  Should  we 
not  have  the  time  for  its  proper  inhalation,  we  may 
inject  a  half  grain  or  more  of  morphine  under  the  skin, 
which  will  produce  a  rapid  blunting  of  nervous  sensi- 
bility ;  and  in  fivo  minutes,  or  even  in  less  time,  the 
patient  will  be  in  a  lit  condition  to  stand  the  operation 
with  the  least  degree  of  constitutional  shock. 

In  tin'  performance  of  all  serious  operations,  when 
possible,  there  should  be  three  assistants.  One  aid 
gives  the  chloroform;  a  second  compresses  the  main 
artery,  which  is  much  better  than  using  the  tourniquet 
— an  instrument  which  is  now,  in  a  great  measure, 
discarded  from  practice — and  a  third  holds  the  limb 
and  supports  the  flap  during  the  section.  The  aid  who 
administered  the  chloroform  during  the  incisions,  can 
assist  in  ligating  the  arteries.  -Military  surgeons  pre- 
fer the  circular  operation  to  the  flap,  which  they  only 
use  in  the  exceptional  cases.  With  the  circular  stump, 
covered  only  by  skin,  there  is  less  soft  tissue  to  sup- 
purate  and   slough,  and  a  much  more  rapid  cicatriza- 


MODE    OF    OPERATING.  417 

tion  is  effected.  Experience,  which  has  long  recog- 
nized the  utility  of  the  circular  operation  for  the  leg, 
has  now  generalized  it  as  tho  most  useful  amputation 
for  the  thigh  or  arm. 

As  tjhe  soft  parts,  muscles,  etc.,  are  divided  perpen- 
dicularly to  the  hone  in  the  circular  method,  there 
wrould  be  fewer  blood-vessels  severed,  and  those  would 
he  cut  across  at  right  angles;  wdiile  in  flap  amputations 
a  large  artery  coursing  through  the  flap,  after  passing 
the  point  where  the  circular  incision  would  have  divid- 
ed it,  might  give  off  several  branches,  all  of  which  would 
be  cut,  and  then  so  obliquely  that  they  would  require 
much  more  care  in  ligation.  Small  vessels,  when  cut 
obliquely,  do  not  contract  to  occlusion  as  readil}'  as 
when  divided  perpendicularly  to  their  axis.  Moreover, 
as  t  he  vessels  are  much  more  numerous,  secondary 
hemorrhage  is  more  likely  to  occur  in  flap  than  in  cir- 
cular amputations.  Another  objection  urged  against 
flap  operations  is  that  the  nerves  run  through  the  en- 
tire flap,  and  their  divided  ends  are  exposed  at  the  ex- 
trem  ity  which  forms  the  cicatrix.  The  pressure  upon 
these  ends  by  the  indurated  cicatricial  tissue,  is  a  fre- 
quent cause  of  painful  stumps.  In  circular  amputa- 
tions, the  flap  being  formed  of 'skin  alone,  and  the 
nerves  being  divided  on  a  level  with  the  bone,  there  is 
no  fear  of  like  incarceration. 

The  rapidity  of  making  flaps,  which  is  often  offered 
as  an  inducement  for  adopting  this  method,  should  not 
influence  the-  surgeon  in  his  choice — as,  under  chloro- 
form, a  lew  Beconds,  or  even  minutes,  more  or  less,  is  of 
no  moment  either  to  operator  or  patient,  nor  does  it 
affect  in  any  possible  way  the  final  result.      When  we 

hear  of  surgeons  boasting  thai  they  can  take  oil' a  leg 
in  so  many  seconds,  we  always  attach  to  them  a  desire 
to  gain  the  applause  of  spectators  at  the  exp<  □ 


U8  MODS   OF   OPERATING. 

the  patient's  Bafety.  I  have  seen  operators  belonging 
to  this  class  who  would  make  a  frightful  gash  in  peri- 
neum and  bladder,  so  as  to  ensure  the  extraction  of  a 
calculus  in  the  shortest  possible  time,  to  the  wonder 
and  astonishment  of  a  large  assemblage  of  professional 
men,  while  a  tew  dayi  of  fatal  Buffering  would  disclose 
the  price  at  which  tin-  false  reputation  ha-  been  pur- 
chased. The  spectators)  however,  who  lose  Bight  of 
the  case,  know  nothing  of  this  natural  consequence. 
Safety  to  the  patient  is  of  the  first  moment,  rapitli ty 
in  performing  an  operation  being  altogether  of  sec- 
ondary consideration.  The  reputation  of  a  surgeon 
should  be  measured  by  his  successful  cases,  ami  not  by 
the  number  of  seconds  he  takes  to  slay  his  patients. 

Saving  assigned  the  aids  to  their  posts,  and  seen 

that  all  the  DOCeSSary  instruments  which  may  he  need- 
ed are  at  hand — for  a  surgeon  should  never  commence 
an  operation  until  he  has  satisfied  himself  on  this  score 
— the  Burgeon  removes  the  limb,  ligates  the  vessels,  ami, 
when  all  OOzing  has  ceased,  secures  the  stum])  hy 
points  of  suture  placed  at  intervals  of  an  inch,  or  a 
little  less,  along  the  entire  line  of  wound. 

In  dividing  the  shin,  the  surgeon  can  not  be  too  careful 
to  leave  <ni  ample  tl<i/>  t<>  cover  the  /i<;i</s  of  the  bones. 

This  is  the  first  and  most  important  rule  in  amputat  ion. 
You  can  not  well  leave  too  much  skin,  ami  can  very 
easily  commit  the  opposite  error.  The  surplus  of  skin 
will  he  absorbed}  a  deficiency  can  in  no  way  be  sup- 
plied. The  rule  is,  to  have  the  flaps  so  ample  that  no 
tension  he  necessary  in  closing  the  wound.  One  of 
the  most  constant,  as  well  as  one  of  the  most  frightful, 

exhibitions  in  those  military  hospitals  where  the  sur- 
geons have  not  yet  gained  experience,  is  the  protrusion 
of  the  hones  from  the  Btumps  of  amputated  legs,  m- 
oessitating  a  second  operation  should  the  patient  Bur- 


MODE   OF    OPERATING.  419 

vivo  the  first.  A  little  care  will  obviate  this  (rouble, 
and  Bave  the  surgeon  much  mortification.  Any  omis- 
sion in  this  respect  must  be  corrected  before  the  stump 
is  dressed  ;  unci  if  the  hone  is  found  so  long  that  the 
skin  can  not  be  made  to  cover  it  without  traction,  re- 
move a  section  of  bone  Avith  the  saw,  and  not  attempt, 
through  want  of  honesty,  to  conceal  a  badly-perform- 
ed operation,  and  make  the  innocent  patient  the  victim 
of  our  misplaced  pride.  In  ll.gating  the  vessels,  tie  every 
artery  which  bleeds,  or  is  likely  to  bleed.  It  is  not  deroga- 
tory for  a  surgeon  to  apply  ten,  fifteen,  or  even  twenty 
ligatures  to  a  stump;  it  shows  that  he  understands 
his  profession;  experience  has  taught  him  the  great 
trouble  and  annoyance  of  reopening  a  stump  to  find  a 
bleeding  vessel,  when  ho  has  but  little  time  to  attend 
to  the  urgent  demands  of  the  wounded.  The  rule  is, 
neglect  no  small  artery. 

As  adhesive  straps  for  supporting  and  sustaining  the 
flaps  arc  antagonistic  to  water  dressings,  they  are 
useless  in  amputations,  and  are  not  used.  Only  a  small 
strap  is  necessary  to  secure  the  ligatures  upon  the  limb 
at  one  angle  of  the  wound,  and  prevent  these  threads 
from  being  unintentionally  pulled  off  from  the  vessels, 
before  the  processes  necessary  for  obliterating  perma- 
nently the  arteries  have  been  completed.  Sutures  are 
recommended  in  all  operations,  and,  in  amputations, 
should  be  sufficiently  numerous  to  keep  the  Haps  in 
perfect  apposition.  As  they  arc  not  removed  for  four 
or  five  days,  they  obviate  much  after-dressing.  A  sin- 
gle layer  of  wot  cloth  is  applied  to  the  stump ;  this,  in 
turn,  is  covered  by  a  piece  of  waxed  cloth  or  oiled  silk 
t"  keep  in  the  moisture,  and  either  an  ice  bladder  or 
water  by  irrigation  is  continuously  applied  over  this 
outer  cloth.  The  <ase  should  now  he  looked  upon  ;is  H 
wound,  and  should  be  treated  accordingly.     The  course 


IJo  TREATMENT   OF   AMPUTATIO 

laid  down  for  wonnds  is  here  strictly  applicable,  and 

should  be  closely  followed. 

hi  certain  eases  of  amputation,  as  in  the  circular, 
■where  the  skin  alone  forms  the  flap,  the  dressing  may 
!><•  changed,  as  follows:  After  applying  suture-  to  the 
entire  Length  of  the  wound,  draw  the  intervening 
sp.-ucs  accurately  together  by  means  of  strips  of  isin- 
glaSS-plaster,  and  cover,  also,  the  length  of  the  wound 
with  a  folded  strip  of  the  same,  only  leaving  uncov- 
ered the  most  dependent  angle  where  the  ligatures 
escape,  and  where  drainage  from  within  is  permitted. 
The  ohject  of  the  dressing  is  to  convert  the  wound 
into  a  suheutancous  one,  excluding  the  air  and  hasten- 
ing union.  To  the  stump  no  Other  dressing  is  applied 
than  a  wet  (doth,  frequently  renewed  or  kept  moist  by 
irrigation.  At  the  expiration  of  a  week,  the  removal 
of  the  straps  will  show  complete  cicatrization  along 
the  line  of  incision.  In  healthy  patients,  and  in  a  pure 
atmosphere,  a  rapid  healing  of  stumps  may  in  this 
way  he  obtained.  The  isinglass-plaster  will  alone 
answer  for  this  dressing — the  diachylon  being  too 
irritating,  and  not  sufficiently  pliant  to  seal,  hermeti- 
cally, the  wound.      We  6nd  hut   little  use  for  ointments 

in  dressing  recent  stumps — the  wet  cloth  being  much 
simpler,  not  irritating,  and,  therefore,  more  efficient. 

Dining  the  treatment  of  all  wounds  in  military  hos- 
pitals, previous  want  and  exposure,  which  belongs  to 
every  army,  however  well  organized,  will  show  their 
influence;  and  if,  from  misguided  views  of  the  pathol- 
ogy of  inflammation,  the  plan  of  abstemious  or  anti- 
phlogistic diet  he  adopted  for  those  operated  upon, 
the  mortality  will  be  heavy.  Liberal  feeding  shows 
its  good  effects  in  the  after-treatment  of  amputations; 
and  the  great  difference  in  the  surgical  statistics  of 
the    French  and  English  depends  more,  perhaps,  upon 


ACCIDENTS    TO    STUMPS.  421 

the  diet  in  their  hospital  practice  than  upon  an}'  one 
other  cause.  Tisanes  can  not  support  a  person  in  or- 
dinary health,  and  certainly  can  not  support  him  un- 
der the  additional  drain  of  an  exhausting  suppuration. 
If  patients  are  placed  under  identically  similar  condi- 
tions, the  successful  treatment  of  amputations  will  he 
found  to  lean  to  the  side  of  those  who  are  the  most  lib- 
erally supported.  Slops  are  out  of  place  in  a  surgical 
hospital,  and  good  cooking  will  be  found  as  useful  as 
good  nursing.  Let  nature  be  our  guide.  For  the  first 
one  or  two  days  after  a  serious  operation,  there  is  but 
little  disposition  to  eat.  Under  such  conditions,  1 
would  not  advise  food  to  be  forced  ;  but,  as  soon  as 
the  patient  expresses  a  desire  to  cat,  foster  his  appe- 
tite with  good,  strong,  nourishing,  easily-digested 
food,  and  let  his  supply  be  liberal.  Any  attempt  at 
starvation  will  be  highly  injurious. 

If  the  patient  escapes  the  ordinary  diseases  inci- 
dent to  hospitals,  viz:  erysipelas,  gangrene,  pyaemia, 
etc., — we  must  be  extremely  careful  of  him  about  the 
tenth  or  twelfth  day.  When  the  ligatures  are  escap- 
ing from  the  arteries,  absolute  rest  should  be  insisted 
upon,  and  the  patient  should  not  be  allowed  to  exert 
himself  in  any  way  until  this  fear  of  secondaiy  hem- 
orrhage is  passed.  We  have  elsewhere  stated  how 
this  complication  is  to  be  met. 

Among  the  accidents  to  which  recent  stumps  are 
exposed,  we  find  hemorrhages,  spasmodic  twitchings, 
excessive  sensitiveness,  often  amounting  to  severe 
pain,  and  protrusion  of  bone,  with  necrosis.  When, 
upon  examination,  a  few  hours  after  a  stump  has 
been  dressed,  it  is  found  hard,  enlarged,  and  glisten- 
ing,- with  the  sntuies  drawn,  and  apparently  burying 
themselves  in  the  skin,  the  patient  complaining  of  the 
pain  of  tension,  the  cause   will   be  found   in   internal 


\22  Aft  ll> I  M>    TO    BTUMT8. 

hemorrhage.  Under  the  sedative  action  of  lot 
blood,  or  the  depressing  effects  of  pain,  etc.,  the  heart's 
action  had  Itch  bo  lowered  that  a  condition  approach- 
ing syncope  had  been  brought  about,  accompanied  by  ■ 
tardy  and  feeble  circulation.  Such  vessels  which  bled 
freely  when  firsl  divided,  under  this  loss  of  vis  a  tcrgo 
fbroe,  ceased  to  bleed.  The  stump  looked  dry,  and  was 
closed  by  suture.  As  Boon  as  the  patienl  gets  warm  un- 
der reaction,  blood  is  driven  with  more  force  through 

open-mouthed  vessels,  the  small  clot  which  tem- 
porarily plugged  them  is  dislodged,  and  the  cavity  of 
the  stump,  made  complete  by  the  close  apposition  <>1 
the  flaps,  is  gradually  tilled  with  blood.  If  there-  be  no 
outward  escape  for  the  blood,  it  clots,  and  thus  stop- 
ping the  orifice  Of  the  vessel,  permits  the  more  per- 
manent clots  to  form  within  the  divided  calibre — so 
that  often,  when  the  Butures  are  cut,  the  stump  freely 
opened,  and  theclotted  blood  emptied  out,  no  bleeding 

1  can  be  found.  Should  the  bleeding  point  be 
discovered,  a  ligature,  which  should  have  been  used 
during  the  operation,  must  now  be  applied.  It  is  the 
frequent  occurrence  of  such  accidents,  necessitating  a 
reopening  of  stumps,  thai  teaches  an  experienced 
surgeon  t<>  negleol  no  bleeding  vessel,  [f  there  arc 
too  many  small  oozing  points,  and  the  surgeon  is  de- 
sirous of  leaving  as  few  ligatures  in  the  wound  as 
possible,  I  have  found  that  forcibly  breaking  a  thread 
around  these  small  vessels  will,  by  cutting  through 
their  inner  contractile  coats,  crush  their  walls  to  the 
obliteration  of  their  calibre,  and  thus  put  a  Btop  to 
the  bleeding,  without  the  necessity  of  leaving  the 
thread  in  the  wound.  When  such  hemorrhages  occur 
after  a  stump  has  been  dressed,  it  is  necessary  to  re- 
move the  clot  from  the  cavity  of  the  stump,  so  as  to 
obtain,  if  possible,  direct  union  between  the  flaps. 


OOZING    FROM   FACE   OF   STUMP.  423 

Under  certain  conditions  there  is  a  general  oozing 
from  the  entire  surface  of  the  stump,  which  is  very 
difficult  to  control,  and  Which  depends  upon  a  hemor- 
rhagic diathesis  induced  by  the  depressing  influences 
of  camp  life.  Legouest,  in  his  Crimean  experience, 
mentions  many  instances  of  this  capillary  oozing. 
Direct  pressure  upon  the  bleeding  surface,  the  eleva- 
tion of  the  stump,  cold  applications,  the  local  applica- 
tion of  the  persulphate  of  iron,  and  indirect  pressure 
upon  the  main  vessel,  will  suffice  to  stop  this  drain. 
As  this  condition  will  likely  induce  an  unhealthy  ac- 
tion in  the  stump,  and  probably  sloughing,  with  secon- 
dary hemorrhage,  the  general  system  of  the  patient 
must  be  improved  by  liberal  diet.  Secondary  hemor- 
rhage, which  comes  on  from  the  eighth  to  the  fifteenth 
day,  about  the  period  of  separation  of  the  thread  from 
the  main  vessel,  will  be  met  by  ligating  the  artery  in 
the  stump,  if  possible,  or  above  it,  according  to  the 
rules  laid  down  so  fully  in  page  207. 

"We  sometimes  observe,  after  amputation,  that  an 
irregular  action  is  excited  in  the  divided  muscles,  with 
a  tendency  t<>  contraction  or  twitching,  which  causes 
the  stump  to  be  disturbed,  moving  it  from  its  position, 
or  even  lilting  it  from  the  bed  upou  which  it  is  lying. 
As  every  movement  of  the  sensitive  extremity  is  very 
painful,  this  spasmodic  muscular  action  in  the  stump 
becomes  an  annoying  complication,  which  demands 
control  from  medicines.  A  bandage  applied  around 
the  limb  is  often  used  to  allay  these  twitchings,  and  is 
supposed  to  be  beneficial  by  the  pressure  and  support 
which  it  affords  t<>  the  divided  muscles.  Mosl  frequents 
ly,  however,  some  one  of  the  nervous  sedativ. 
which  opium  is  the  chief,  i>  oecessary  to  quiel  this 
ilar,  painfUl  action.  This  spasmodic  action  of 
the  muscles  accompanies  recent   amputation,  :md  i- 


l'_'4  PAINFUL   BTDMP.  '^^^^.^M 

rardy  scon  whori  the  operation  has  been  performed 
0v<  r  ten  or  fifteen  da; 

When  cicatrization  has  commenced,  a  Bocond  acci- 
dent may  appear,  consisting  in  a  severe  pain  locating 
itself  in  the  end  of  the  stamp,  and  often  radiating  up 
the  lim!>.  The  pain  is  one  of  pressure  or  tension,  and 
is  at  times  very  severe.  It  is  accounted  for  by  an 
incarceration  of  the  ends  «>t'  the  divided  nerves  in  the 
cicatricial  tissue,  which,  in  hardening,  exercises  pain- 
ful pressure  upon  them.  This  condition  is  not  so  like- 
ly 1"  occur  in  circular  as  in  flap  amputations,  as  the 
cicatricial  lino  in  one  case  is  formed  of  skin  alone, 
while  in  flap  operations  the  nerves  extend  to  the  very 
extremity  of  the  (lap,  ami  arc  often  incorporated  in 
icatrix.  ruder  certain  circumstances  a  morbid 
action  is  Bel  up  in  the  extremity  of  the  divided  q< 
with  exudation  among  the  nerve  filaments,  resulting 
in  the  formation  of  a  tumor  which  incorporates  ami 
compresses  painfully  the  extremity  of  the  nerve  trunk. 
Whenever  persistent  pain  exists  in  a  healed  stump 
which  anodynes  can  not  remove,  some  such  patholog- 
ical condition  must  he  suspected,  and  the  compressed 
nerve  be  liberated,  <>r  its  diseased  extremity  exoised. 

The  mosl  important  accident  to  which  a  stump  is 
liable  is  from  exposed  bone,  called  usually  a  conical 
stum] i,  the  pathology  of  which  is  not  generally  under- 
stood. This  condition  has  been  very  frequently  at- 
tributed to  carelessness  in  operating,  and  by  many  is 
always  traced  to  a  deficiency  of  flap.  Experienced 
surgeons,  however,  meet  with  this  condition  of  pro- 
truding hone  where  every  care  had  been  taken  during 
the  amputation   to  leave  even  a  superabundance  of 

soft  parts,  and  where  the  end   of  the  hone  was  amply 

covered.    Again,  its  presence  has  been  attributed  to  an 
irritability  of  the  muscular  envelopes  of  a  stump  which, 


CONICAL   STUMPS.  42.r> 

by  their  excessive  retraction,  expose  the  end  of  the 
bone.  There  is  no  doubt  that  the  muscles  do  retract, 
but  instead  of  the  cause,  it  is  rather  as  the  effect  of  a 
previously  existing  disease.  The  true  cause  of  conical 
stumps  is  found  in  an  inflammation  of  the  lining  en- 
velopes of  the  bone,  both  periostial  and  medullary,  but 
more  especially  the  latter.  Either  from  some  peculiar 
condition  of  the  patient  or  atmosphere,  or  from  the 
direct  injury  which  these  nutrient  membranes  of  the 
bone  receive  from  the  saw,  an  inflammation  is  excited. 
The  medullary  membrane  takes  on  the  general  suppu- 
rative inflammation  with  all  the  tissues  of  the  stump. 
It  becomes  red,  swollen,  and  thickened,  soon  filling  up 
the  entire  medullary  canal,  and  even  protruding, 
fungus-like,  from  the  smoothly  cut  end  of  the  bone. 
In  connection  with  this  inflammation,  the  nutrition  of 
the  bone  becomes  impaired,  the  periosteum  as  well  as 
the  medullary  membrane  separates  from  the  exposed 
end,  which  leaves  a  white,  denuded,  osseous  rim.  The 
soft  parts  of  the  stump  will  not  unite  over  this  fungoid 
mass  from  the  medullary  cavity,  but,  gradually  re- 
ceding on  all  sides,  leaves  it  eventually  the  most 
prominent  portion  of  the  surface.  From  exposure  the 
bone  is  darkened,  and  the  medullary  granulations 
desiccate  into  a  hard,  black,  greasy  crust,  intimately 
attached  to  the  end  of  the  bone.  In  the  progress  of 
the  case,  under  Long-oontinued  suppuration,  with  the 
formation  of  sinuses  and  fistulous  openings,  the  en- 
velopes of  the  bone  still  further  separate  from  the  ex- 
tremity of  the  shaft,  so  thai  a  probe  can  pa--  up.  for 
some  distance,  alongside  of  the  bone. 

In  the  meantime  nature  has  set  up  her  eli  mi  native 
action,  and  by  slow  steps  is  isolating  the  denuded,  ne- 
crosed portion.     After  many  weeks  Borne  motion  can 
be  imparted  to  the  blackened  protruding  prominence 
J  j 


420  OAL    STL  KPB. 

■  in-.  .-Hid  soon  after  it  is  round  s<>  detached  that  it 
can  be  palled  off,  coming  away  as  an  irregular  cylin- 
der, Bmoothlycut  where  the  -aw  had  traversed  it.  bul 
very  apioalated  in  the  direction  of  the  Bhaft.  These 
prolongations  are  eometimea  four  and  five  inches  long, 
showing  to  what  a  distance  th<'  disease  had  extended 
in  the  medullary  cavity. 

As  the  pathology  of  conical  stumps  eau  be  clearly 
traced  to  a  destructive  inflammation  of  the  medullary 
and  periostial  membranes,  the  plan  oftreatmonl  can  be 
as  clearly  laid  down.  No  benefit  can  bo  derived  from 
a  course  recommended  of  making  traction  upon  the 
soft  parts  by  means  of  bandages  and  plasters,  bo  as  to 
draw  the  muscles  of  the  stump  over  its  extremity. 
The  result  would  be  the  incarceration  of  a  necrosed 
bone.  Nor  is  the  risk  of  a  Becond  amputation  justifia- 
ble, as  no  Burgeon  can  foretell  the  extentof  the  inflam- 
mation, and  to  what  beight  the  disease  lias  involved 
the  Bhaft.  In  cutting  off  an  inch  of  the  bone  we  may 
leave  two  or  three  inches  of  sequestra  behind.  The 
only  judicious  course  to  pursue  in  the  accident  of 
conical  st  u in] >>,  is.  to  await  patiently  the  elimination  of 
the  dead  hone,  knowing  that,  in  time,  the  entire  extent 
of  diseased  bone  will  become  detached,  and  can  bo 
readily  removed,  when  the  stump  will  heal  rapidly. 
The  history  of  this  war  has  given  us  interesting  cases 
in  which  medullary  necrosis,  following  upon  amputa- 
tions in  the  middle  of  the  thigh,  had  exfoliated  the  Bhaft 
of  the  bone  as  high  up  as  the  trochanter.      JtB  the  rule 

of  treatment  for  conical  st  umps  with  necrosed  bone  is  to 

await  patiently  the  separation,  any  instrumental  in- 
terferenoe  is  meddlesome  surgery,  and  always  injurious. 

Whenever  operations  are  to  be  performed  in  mili- 
tary surgery,  Chloroform  should  be  administered.  It  is 
a  remedy  which  the  surgeon  should  never  be  without, 


TJSE   OP   CHLOROFORM. 


427 


and  which  might  be  used  on  all  occasions  with  advan- 
tage, whether  for  operations  or  for  dressing  painful 
wounds,  as  in  the  cleansing  of  compound  fractures. 
The  effects  of  chloroform  are  wonderful  in  mitigating 
the  suffering  of  the  wounded,  and  it  is  often  instru- 
mental in  the  cure  of  wounds,  from  the  rest  and  tran- 
quillity of  mind  which  follows  its  inhalation.  It  also 
prevents  excessive  reaction  in  the  paroxyms  of  trau- 
ma lie  fever.  During  the  performance  of  capital  oper- 
ations on  the  battle-field,  death  sometimes  ensues 
from  nervous  exhaustion,  produced  by  excess  of  suf- 
fering; the  use  of  chloroform  relieves  the  patient  at 
least  from  this  risk. 

The  universal  use  of  chloroform  to  allay  the  pain  of 
surgical  operations,  is  a  complete  vindication  of  the 
utility  of  the  remedy,  and  proof  of  its  necessity.  For 
ourselves,  we  place  unlimited  confidence  in  itsjudicious 
administration,  arrd  use  it  without  hesitation  under  any 
circumstances.  We  l*ope  that  the  humanizing  tenden- 
cies of  the  age,  in  introducing  this  invaluable  comfort, 
has  banished  that  dread  of  being  cut  as  an  item  to  be 
considered  when  operations  are  necessary;  and  we 
hope  to  see  anaesthetics  used  as  liberally  in  allaying  the 
pain  of  surgical  affections  as  cold  water  is  now  used 
for  keeping  down  inflammation.  We  do  not  hesitate  to 
say,  that  it  should  be  given  to  every  patient  requiring  a  se- 
rious or  painful  operation.  We  may  hear,  now  and  then, 
Of  an  accident  from  its  administration;  but  who  can  tell 
us  of  the  immense  number  who  would  have  sunk  from 
operations,  had  ii  not  been  administered? 

In  iis  administration  we  must  use  the  following  pre- 
cautions: The  besl  apparatus  is  a  folded  cloth,  in  the 
form  of  a  cone,  in  tin'  apex  of  which  a  small  piece  of 
Sponge  is  placed.  This,  is  at  first  held  a!  some  distance 
from  the  nose  ami  mouth  of  the  patient,  80  that  tlu- 


428  USE    OF   CHLOROFORM. 

first  inhalation  may  be  well  diluted  with  air.  As  the 
exhilarating  Btage  is  reached,  the  cloth  should  be  ap- 
proached to  the  nose,  so  that  a  more  concentrated 
ether  may  be  inhaled,  which  will  rapidly  produce  the 
desired  insensibilit}7.  Noisy  breathing  is  the  sign  that 
the  anaesthetic  effect  is  produced,  when  the  inhalation 
should  be  suspended,  and  the  operation  commenced. 
Unless  the  operation  is  very  tedious,  do  not  renew  the 
inhalation. 

Ingenious  inhalors  are  more  or  less  complicated,  and 
are,  on  that  account,  more  or  less  inefficient.  The 
great  perfection  of  the  above-mentioned  apparatus  is 
its  simplicity.  Finding  that  much  chloroform  is  wasted 
by  evaporation  from  the  handkerchief,  I  have  for  some 
years  used  a  common  funnel  as  my  inhalor,  which  pro- 
tects the  hands  of  the  person  administering  the  chlo- 
roform,  and  prevents  the  loss  from  general  evaporation. 
If  a  piece  of  heavy  wire,  or  a  small"  bar  of  tin,  be  at- 
tached across  the  interior  of  the  tkinnel,  about  half-way 
toward  its  throat,  the  sponge  containing  the  chloro- 
form can  be  supported  between  this  bar  and  the  side  of 
the  funnel,  leaving  a  space  on  one  side  for  the  air  to 
rush  over  the  surface  of  the  sponge  as  it  comes  through 
the  elongated  end  of  the  apparatus,  when  the  air, 
loaded  with  ether,  is  inhaled.  The  funnel  should  bo 
large  enough  to  coyer  the  lower  half  of  the  face,  in- 

eluding  the  nose  and  mouth,  and  the  sponge  should 
not  come  within  two  inches  of  the  face — for,  should  it 
touch  the  skin,  it  would  blister  it.  The  eyes,  being  ex- 
cluded from  the  apparatus,  are  not  annoyed  by  the 
evaporation  of  chloroform.  As  the  tunnel  does  not  tit 
accurately  to  the  lower  outline  of  the  face,  there  will 
be  ample  spaces  on  either  side  of  the  chin  to  admit  air 
for  diluting  the  vapor. 

Besides  a  great  saving  of  chloroform,  which  is  no 


USE   OF    CHLOROFORM.  429 

small  recommendation,  the  use  of  this  instrument  ob- 
viates the  fear  of  suffocation,  which  is  always  present 
to  my  mind  when  I  see  chloroform  carelessly  adminis- 
tered. When  the  cloth  is  used,  should  the  patient 
struggle — a  very  common  occurrence — or  should  the 
assistant  administering  the  anaesthetic  be  at  all  inter- 
ested in  the  operation,  the  cloth  is  thrust  down  upon 
the  face  of  the  patient,  respiration  is  impeded,  and  suf- 
focation is  imminent.  Suppose  the  patient  has  already 
been  influenced  to  such  an  extent  that  he  has  lost  the 
voluntary  control  of  his  muscles,  and  can  not  pull 
away  the  cloth,  he  is  in  a  very  dangerous  condition, 
and  the  continued  thoughtlessness  of  the  assistant 
might  suffocate  him.  I  can  readily  understand,  in  this 
way,  why  deaths  should  sometimes  occur  from  the 
carelessness  of  administration,  and  am  only  surprised 
that  it  occurs  so  seldom.  Were  we  as  careless  in  the 
use  of  other  potent  remedies  as  we  are  of  chloroform, 
cases  of  poisoning  would  be  largcl}'  increased.  In 
times  of  hurry,  confusion,  and  excitement,  as  after  a 
battle,  we  can  not  surround  the  safety  and  well-being 
of  the  wounded  with  too  many  guards  for  their  pro- 
tection. 

Of  the  many  thousand  instances  of  its  administra- 
tion since  the  war  between  the  Confederate  States  and 
United  States  began,  but  two  fatal  cases  from  chlo- 
roform inhalation  have  been  reported.  In  one,  the 
patient  'lied  in  a  few  minutes  after  inhalation  was  com- 
menced. In  the  other,  the  patient  did  not  die  for  sev- 
eral hours.  The  case  was  that  of  a  healthy  young 
soldier,  who  bad  a  minie  hall  embedded  under  the 
scapula,  and  who,  while  >  n  /out,  to  rejoin  his  command, 
Btopped  at  a  hospital,  ami  desired  its  removal.     The 

Operation  was  very  tedious,  and  he  was  kept  under  the 

influence  of  chloroform  for  one  and  a  half  hours.     Al- 


430  STIFF   JOINTS   FROM    GUNSHOT    WOUNDS. 

though  he  regained  his  consciousness  when  the  admin- 
istration was  stopped,  his  pulse  never  reacted,  notwith- 
standing the  liberal  use  of  brandy.  A  few  hours  alter 
the  operation  was  completed  there  appeared  an  in- 
creasing disposition  to  sleep,  which  gradually  ended 
in  coma,  the  pulse  becoming  more  and  more  feeble. 
He  died  thirty-two  hours  after  the  inhalation.  As  the 
operation  affected  no  vital  part,  and  as  the  health  of 
the  patient  was  good,  his  death  could  be  attributed  to 
no  other  cause  than  the  inhalation  of  chloroform. 

Stiff  Joints  and  Deformed  Limbs. — I  have  had  my 
attention  frequently  called  to  the  number  of  anchylosed 
limbs,  resulting  from  gunshot  fractures  of  the  shaft  of 
a  bone,  or  even  from  simple  flesh  wounds.  These  de- 
formities are  caused,  in  most  instances,  b}r  the  misap- 
plication of  splints  and  bandages.  Nothing  is  more 
common,  in  army  experience,  than  to  see  a  sling  worn 
for  months  for  a  gunshot  wound  of  the  arm  or  forearm. 
The  injury,  usually  a  compound  fracture,  or  perhaps 
only  a  flesh  wound,  after  some  days'  treatment  in  a 
hospital,  may  have  been  found  so  rapidly  improving 
that,  with  the  prospects  of  an  early  cure,  the  patient 
was  given  thirty  days'  furlough,  and  sent  home.  From 
neglect,  or  injudicious  treatment,  the  process  of  the 
cure  was  retarded;  and,  after  an  extension  of  furlough 
of  thirty  days,  he  reports  to  a  hospital  or  examining 
board  with  wound  healed,  but  with  a  stiff  joint.  Wounds 
of  the  forearm  frequently  leave,  as  sequelae,  when  they 
are  not  properly  watched,  contracted  fingers  and  stif- 
fened wrists.  Anchylosis  of  the  elbow  is  also  afrequent 
accompaniment  of  such  injuries,  as  well  as  of  injuries 
of  the  arm. 

During  the  treatment  of  every  gunshot  wound  of  the 
upper  extremity,  when  it  is  necessary  to  carry  the 


STIFF   JOINTS- FROM    GUNSHOT    WOUNDS.  431 

forearm  and  hand  upon  a  board,  or  the  arm  in  a  sling, 
it  is  the  common  custom  to  wear  the  apparatus  until 
the  wound  is  perfectly  healed.  When  this  is  accom- 
plished, the  patient  throws  aside  the  sling;  but  finding 
that  the  limb,  after  being  carried  for  a  long  time  in  an 
elevated  position,  is  congested  immediately  when  it  is 
allowed  to  hang,  ho  becomes  alarmed  at  its  swollen, 
discolored,  ^md  painful,  or  rather  benumbed,  condition. 
After  a  few  minutes'  trial  he  elevates  the  limb,  and  as 
he  finds  in  it  immediate  relief  from  these  disagreeable 
sensations,  he  reapplies' the  apparatus,  with  the  inten- 
tion of  wearing  it  until  his  arm  becomes  strong  enough 
to  bear  the  depression.  In  this  opinion  he  is  often 
sustained  by  his  physician,  who  tells  him  that,  eventu- 
ally, all  will  get  right.  After  frequent  attempts  at  al- 
lowing the  limb  to  hang,  with  the  same  results  as  at 
first,  he  gives  up  all  hope  of  ever  getting  the  use  of  his 
arm,  and  carries  if  day  and  night  in  a  sling.  Unless  he 
is  exceedingly  fond  of  the  excitement  of  an  active  cam- 
paign, he  rather  cajoles  himself  with  the  frequent  re- 
newal of  his  furlough.  Eventually  he  finds  that  he  has 
lost  all  power  of  movement  in  the  clbowr-joint,  which 
has  become  anchyloscd.  In  gunshot  wounds  of  the 
thigh  and  leg  a  similar  stiffening  of  the  knee-joint  often 
results  from  the  position  in  which  the  leg  is  for  a  long 
time  carried — semiflexed,  to  relieve  the  painful  tension 
of  the  muscles. 

When  a  limb  has  been  supported  for  even  a  few  da ys, 
the  veins  appear  to  lose  their  tonicity,  and  are  easily 
distended  b}-  the  weight  of  a  column  of  blood;  so  that, 
when  the  arm  or  leg  is  lnmg  downward,  the  blood  stag- 
nating in  the  veins  distends  all  of  these  vessels,  con- 
gesting the  limb,  and  producing  a  painful  exaggeration 
of  numbness.  Should  there  be  an  ulcer  upon  the  ex- 
tremity, venous  blood  will  at  once  trickle  from  its  but- 


432  STIFF   JOINTS    FROM    GUNSHOT    WOUNDS. 

face — having  burst  through  the  attenuated  walls  of  the 
vessels,  as  the  column  of  blood  exercises  more  pressure 
than  these  feeble  vessels  can  bear.  This  loss  of  tone 
is  readily  restored  after  a  few  days'  use  of  the  limb. 

In  cases  where  the  arm  has  required  support  for 
some  time,  as  in  compound  fractures,  when  a  cure  has 
been  perfected,  and  the  necessity  for  using  a  sling  has 
passed,  tbe  following  course  has  been  found,  beneficial : 
After  dropping  the  arm  for  even  a  few  minutes,  as  soon 
as  it  becomes  painfully  congested  it  should  be  raised, 
and  supported  by  thrusting  the  thumb  or  hand  in  the 
buttoned  coat  or  vest.  When  the  arm  has  rested  suffi- 
ciently, allow  it  again  to  hang  down;  and,  by  fre- 
quently repeating  this  manoeuvre,  in  a  few  days  tone 
will  be  restored  to  the  vessels,  and  the  painful  disten- 
sion from  position  corrected.  If  the  medical  attendant 
does  not  urge  the  patient  to  this  course,  and  explain  to 
him  the  pathological  condition,  so  that  he  can  intelli- 
gently assist  himself,  the  tonicity  of  the  vessels  will 
be  daily  deteriorating,  instead  of  the  arm  gaining 
strength.  Frictions  over  the  limb  with  a  stimulating 
embrocation  will  assist  materially  the  member,  and 
even  dry  rubbing  is  found  very  strengthening  to  the 
vessels  by  stimulating  the  nerves,  which,  in  turn,  con- 
trol and  restore  .action  in  the  blood-vessels.  The 
splints,  and  especially  the  sling,  should  be  discarded,  as 
soon  as  they  have  fulfilled  their  usefulness.  Cases  of 
neglect  of  tliis  important  rule  are  so  numerous,  when 
wounded  men  are  allowed  to  be  treated  at  home  on 
furlough,  that  the  propriety  is  very  questionable  of  al- 
lowing them  to  leave  the  hospital,  until  a  cure  is  so  far 
progressed  as  to  enable  them  to  dispense  with  all  ap- 
paratus. 

When  stiff  joints  are  presented  for  correction,  it  is 
important  to  know  whether  the  anchylosis  is  false  or 


.    STIFFENING}    WITHOUT    A    JOINT.  loo 

true;  whether  produced  from  a  permanent  contrac- 
tion of  the  muscles  around  a  joint,  or  from  fibrinous  and 
osseous  formations  within  fhe  articulation  and  between 
the  heads  of  the  bones,  ultimately  joining  these,  or 
even  blending  them.  When  a  wound  has  occurred  at 
some  distance  from  a  joint,  which  has  become  stiff 
during  a  tedious  course  of  treatment,  the  presumption 
is  that  the  anchylosis  is  spurious,  or  resulting  from 
contracted  muscles  and  shortened  ligaments,  the  effect 
of  a  long-continued  and  restrained  position.  If,  when 
an  attempt  is  made  to  straighten  such  a  limb,  strong, 
hard  tendons,  as  cords  or  stays,  are  felt  prominently 
under  the  skin,  preventing  extension,  the  most  speedy 
and  certain  relief  is  found  in  the  subcutaneous  section  of 
such  cords.  Chloroform  is  administered,  and  the  limb 
extended  forcibly  until  the  contracted  tendons  become 
prominent.  A  delicate  tenotomy  knife  is  then  passed 
under  them,  and,  by  turning  the  sharp  edge  of  the 
blade  outward,  exercising,  at  the  same  time,  a  sawing 
motion,  the  tendons  will  suddenly  yield,  and  the  limb 
can  then  be  readily  extended.  It  would  be  bad  policy, 
however,  to  straighten  the  limb  at  once,  inasmuch  as 
the  divided  extremities  of  the  tendons  would  be  so  sepa- 
rated from  each  other  that  a  very  indifferent  bond  of 
union  would  be  formed  between  them.  The  better 
course  is  to  replace  the  limb  immediately  in  its  contract- 
ed position,  and  support  it  in  the  same  by  a  splint  and 
bandage.  At  the  end  of  a  week  the  ends  of  the  divided 
tendon  will  have  been  glued  together  by  an  abundance 
of  plastic  material,  which  will  be  found  so  yielding  in 
its*  character  that,  if  a  splint,  with  a  movable  joint, 
as  seen  in  figure  1,  plate  24,  be  now  attached  to  the 
limb,  and  by  means  of  the  screw  be  gradually  straight- 
ened out  a  little  everyday,  at  the  end  of  three  or  four 
weeks  the  tendons  will  have  become  so  much  elon- 
Kk 


134  BTIfFENlIfp    WITHIN    A   JOINT.     . 

gated  by  the  yielding  of  this  plastic  deposit  as  to 
permit  the  ready  straightening  of  the  limb,  and  the 
removal  of  all  contracting  deformity. 

Plate  24.  figure  1.  shows  tin1  kind  of  angular  splint 
best  adapted  to  false  anchylosis  of  the  elbow,  which  is 
a  very  common  accident  after  a  compound  fracture  of 
the  arm  or  forearm.  Figure  4,  plate  24,  gives  the  de- 
sign of  a  similar  apparatus  for  straightening  the  knee- 
joint.  Where  no  tendons  become  prominent  or  require 
division,  the  angular  splint  alone  will  suffice  for  re- 
moving the  contraction.  The  biceps  tendon  at  tho 
elbow-joint,  and  the  hamstring  muscles  at  the  knee, 
are  the  tendons  requiring  division.  After  section  the 
limb     should     not     be     immediately,     hut     gradually, 

straightened.  With  ordinary  care,  and  a  little  ana- 
tomical knowledge,  the  operation  of  tenotomy  becomes 
a  simple  and  usually  very  successful  expedient.  Per- 
manently Hexed  fingers  and  toes,  when  caused  by  in- 
jury to  the  muscles  of  the  arm  or  leg,  are  veiy  easily 
straightened  by  division  of  the  contracted  tendon. 

When  inflammation  has  occurred  within,  or  in  I  he 
immediate  vicinity  of,  an  articulation,  the  cause  of 
stiffening  is  found  in  a  deposit  of  lymph,  which  ties  the 
heads  of  the  bones  more  or  less  intimately  together, 
restricting  all  movements  in  the  joint.  Such  cases  re- 
quire a  different  treatment.  These  muscles  may  not 
he  immediately  at  fault,  and,  therefore,  would  not  re- 
quire division.  The  proper  mode  of  proceeding  is,  under 
chloroform,  to  flex  forcibly  the  limb,  breaking  up  bands 
of  adhesion.  They  can  be  felt  to  give  way  under  the 
hand,  at  times,  with  an  audible  noise.  In  the  elbow,  as 
well  as  in  the  knee,  the  limb  is  straightened  by  first  flexing 
it.  Bend  the  .forearm  until  if  lies  upon  the  arm,  and 
the  knee  until  the  heel  touches  the  buttock.  By  this 
tbrcible  flexion  the  main  vessels  of  the  extremity,  all 


OSSEOUS    UNION    IN    ANCHYLOSIS.  435 

o?  which  pass  over  the  flexed  portion  of  the  limb,  are 
relaxed  and  not  stretched,  and,  therefore,  injury  to 
them  is  avoided. 

After  complete  flexion  is  effected,  attempts  may  then 
be  made  to  straighten  the  limb,  without,  however,  using 
an  excessive  amount  of  force.  An  angular  splint  is  ap- 
plied, so  as  to  retain  the  degree  of  extension  and  pre- 
vent recontraction.  Inflammation  and  pain  in  and 
about  the  joint  will  likely  arise,  which  will  be  controlled 
by  the  use  of  water  dressings,  either  cold  or  warm,  as 
most  acceptable  to  the  patient-  At  the  end  of  a  week 
or  ten  days,  when  the  redness  and  swelling  has  disap- 
peared, the  splint  should  be  removed,  and  the  limb 
flexed  and  extended,  in  order  to  destroy  any  adhesions 
which  may  have  reformed.  This  manoeuvre  is  re- 
peated daily,  and  continued  until  the  limb  is  straight- 
ened— the  angular  splint  being  reapplied  after  it,  and 
straightened  a  little  more  than  on  the  preceding  day. 
The  splint  must  be  worn  day  and  night;  otherwise  the 
contraction  of  the  muscles,  by  giving  the  most  comfort- 
able position  to  the  limb,  will  restore  the  deformity. 

When  osseous  union  has  taken  place  between  the 
extremities  of  the  bones,  forming  a  joint,  much  more 
force  is  required  to  flex  the  limb;  and  often  the  fusion 
between  the  bones  is  so  complete  that  it  is  found  im- 
possible, by  a  warrantable  degree  of  force,  to  restore 
motion  to  the  joint.  Too  much  violence  is  not  justifi- 
able. If,  b}r  a  moderate  application  of  force,  the  bony 
union  can  be  broken  up,  motion  can  be  eventually  re- 
stored to  the  joint.  Inflammation  will  ensue,  requir- 
ing local  applications  as  well  as  general  treatment  for 
its  control.  When  this  subsides,  passive  motions  of 
the  joint  should  be  daily  made. 

When,  upon  careful  examination,  in  anchylosis  of  the 
knee-joint,  the  patella  H  found  intimately  attached  t" 


186  FROST-BITK. 

the  anterior  faco  of  the  femur,  no  benefit  Can  accrue, 
from  restoring  motion  between  the  extremities  of  the 
femur  and  tibia,  as  the  attachment  of  the  patella  pre- 
vents  all  use  of  the  quadmceps-extensor  muscle, 
which  is  the  anterior  support  and  motive  powerofthe 
leg.  Such  cases  should  not,  therefore.  I>e  interfered 
\v  ith . 


FROST-BITE. 

Among  the  affections  of  the  extremities  which  sur- 
geons in  the  field  are  called  upon  to  treat,  daring  the 
inclemency  of  the  winter's  campaign,  are  those  oc- 
casioned by  exposure  to  oold  and  moisture.  During 
the  winter  months  an  army  usually  sutlers  from  these 
accidents  in  proportion  to  the  privations  which  they 
are  compelled  to  undergo  —  for  well-fed  and  well- 
clothed  troops  do  not  readily  yield  to  the  injurious 
influences  of  exposure. 

During  the  Crimean  war.  the  two  winters  whioh  the 
allied  army  spent  before  SebastOpol  were  very  ditl'er- 
cnt  in  character.  The  winter  of  1864—66  was  not 
very  cold,  but  was  a  season  of  continued  rain;  the 
soldiers  were  literally  living  in  the  mud,  with  wet 
clothes,  which,  for  weeks,  they  had  no  means  of  dry- 
ing; at  the  same  time,  the  difficulty  of  procuring 
supplies  was  so  great  that  their  means  of  subsistence 
kept  them  just  above  starvation.  Sleeping  in  wet 
boots  as  long  as  the  boots  were  whole  enough  to 
remain  on,  and  the  continued  maceration  of  the  feet 
in  snow  and  ice-water,  caused  a  gradual  diminution  of 
the   circulation    and    vitality *©f    th<     toes    and    feet 


FROST-BITE.  437 

Very  short  allowance,  unusual  exposure,  and  very 
indifferent  shelter,  more  than  counterbalanced  the 
absence  of  a  very  low  temperature;  and  the  result 
was  that  extremities,  which  could  barely  be  kept 
alive. would  be  given  over  to  disease  under  a  temper- 
ature which  would,  under  other  conditions,  be  innocu- 
ous. The  feet  and  toes  would  become  swollen  and 
cedematous,  with  a  feeling  of  tension  which  gave 
much  uneasiness  during  the  day,  with  such  an  increase 
of  pain  toward  night  as,  in  many  instances,  to  pre- 
vent sleep;  the  parts  would  be  discolored  of  a  brown- 
ish-red hue.  In  more  serious  cases,  blisters  would 
form  upon  the  discolored  surfaces,  beneath  which 
blood  would  extravasate.  The  drying  and  blacken- 
ing of  this  would  simulate  mortification  so  closely  as 
to  be  mistaken  by  the  careless  observer;  the  peeling 
off  of  this  blackened  pellicle  would,  however,  expose 
either  a  new  skin  or  an  ulcerated  surface.  In  feeble 
constitutions  the  parts  attacked  by  this  low  inflam- 
mation break  down  into  sloughing  ulcers,  character- 
ized, in  their  future  march,  by  chronicity,  and  an 
inactivity  in  the  formation  of  healthy  granulations; 
also  an  excessive  secretion  of  a  highly  offensive,  ichor- 
ous pus,  with  pale,  greyish,  exuberant,  irritable,  very 
painful,  and  bleeding  granulations. 

Like-  hums,  the  effects  of  cold  show  various  degrees 
of  gravity — from  the  redness  and  puffiness  of  a  toe, 
through  blistering  of  the  surface  and  the  formation  of 
superticial  ulcers,  to  the  complete  mortification  of 
extremities  and  putrescent  liquefaction  of  the  soft 
parts — with  the  usual  systemic  irritation,  general 
depression,  and  intestinal  complications. 

A  second  variely  of  frost-bite  was  well  exemplified 
in  the  Crimea  daring  the  winter  of  1855-56..  At  this 
period   the  soldiers  were  better  clothed  and  fed,  all 


l:;^  FROST-BITE. 

the  comforts  of  army  Life  were  at   their  disposal,  and 
the  hygiene  of  the  camp  was  in  every  respect  good. 

The  temperature  of  tliis  winter  was  so  extreme 
that  warm  clothing  could  not  retain  the  degree  of 
heat  necessary  to  support  life  in  the  extremities. 
Those  who  wci-i'  in  in  1 1  exposed  tir>t  lost  all  sensation 
in  their  feet,  so  that  no  feeling  would  be  imparted  to 
the  foot  upon  touching  the  ground,  and  then  found 
some  difficulty  in  walking,  or  even  in  supporting  the 
erect  posture.  The  feet,  upon  examination,  would  be 
found  cold,  livid,  mottled,  slightly  swollen,  hard, 
cedematous,  and  without  sensation.  The  continued 
influence  of  cold  would  destroy  the  limb,  causing  it  to 
shrivel  and  become  dark.  In  time  a  lino  of  demar- 
cation would  form,  and  the  slow  process  of  separation 
commence,  leaving  a  chronic,  fungus,  sensitive  ulcer, 
from  which  a  fetid  pus  would  be  continuously  dis- 
charged for  months.  As  the  fibrous  tissues  resist 
mortification  they  retain  dead,  blackened  bones, 
which  protrude  from  the  face  of  the  ulcer — a  source 
of  much  annoyance,  keeping  up  irritation,  causing 
abscesses  in  the  vicinity,  and  extending  the  mischief 
to  contiguous  bones.  Should  any  attempt  be  made  to 
remove  these  protruding  and  hanging  phalanges,  con- 
stitutional irritation,  with  increased  pain,  and  a  fungus 
condition  of  the  ulcer,  if  not  gangrene,  were  sure  to 
follow. 

The  treatment  which  is  found  most  useful  in  cases 
of  frost-bite  would  be  of  a  stimulating  character, 
avoiding  studiously   the   application  of  heat   in   any 

form. 

» 

Cold  water  and  ice  play  an  important  part  in  the 
treatment  of  the  local  injuries  induced  by  intense  cold. 
Where  the  parts  are  swollen,  painful,  and  discolored, 
frictions,  with  snow  or  ice  water,  is  the  popular  mode 


TREATMENT    OF   FROST-BITE.  439 

of  treatment  in  arctic  climates,  where  experience  dur- 
ing the  winter  months  verify  its  advantages.  The 
frictions  stimulate  the  tissues  in  which  vitality  has 
been  depressed,  while  the  continued  application  of  cold 
prevents  an  cxeUed  action  from  overwhelming  the 
weakened  tissues  and  crushing  out  the  little  life  re- 
maining. These  cold  applications  must  be  persever- 
ingty  continued  for  several  days.  Even  when  insuffi- 
cient in  themselves,  they  seem  to  increase  the  remedial 
power  of  other  remedies.  Similar  results  are  obtained 
by  local  applications  of  spirits  of  camphor,  tux-pentine, 
or  sugar  of  lead  and  laudanum,  or  by  painting  the  parts 
with  tincture  of  iodine  or  a  solution  of  nitrate  of 
silver,  or  diluted  nitric  acid.  Tannic  acid,  dissolved  in 
glj-cerine,  is  highly  extolled  in  chilblains,  even  who  n 
accompanied  with  ulceration.  Under  such  applica- 
tions the  local  symptoms  will  gradually  disappear. 
For  the  more  serious  grades,  with  ulceration,  stimu- 
lating and  narcotic  applications  will  be  found  the 
most  useful,  although  a  tedious  cicatrization  will 
accompany  the  most  judicious  treatment. 

When  mortification  threatens,  never  use  warm  poul- 
tices, which  I  have  seen  applied  in  such  cases — a  cer- 
tain means  of  ensuring  an  extensive  destruction — but 
by  frictions  with  cold,  stimulating  substances,  try  to 
excite  new  action  in  the  parts;  and,  should  the  general 
system  have  been  much  depressed,  stimuli  and  nourish- 
ing food,  with  the  tonic  preparations  of  iron,  should 
be  administered.  Until  the  line  of  separation  between 
the  'lead  and  Living  parts  is  well  established,  and  the 
neighboring  tissues  have  lost  their  discoloration,  swell- 
ing, and  induration,  no  amputation  should  be  perform- 
ed, as  gangrene  is  likely  to  follow  the  irritation  pro- 
duced by  the  knife  in  such  diseased  tie  Ls,how- 
ever,  these  slowly  decomposing  masses  would  poison 


110  TREATMENT    OF    IMtOST-IMTE. 

tlir  atmosphere  of  a  hospital  by  putrefactive  emana- 
tions, the  course  which  was  round  most  successful  WB8 
to  cut  away  the  dead  masses,  and  remove-the  sloughs, 
hut  without  touching  the  living  tissues. 

In  the  majority  of  eases  those  surgeons  who  cut  off 
the  bones  at  tin-  face  of  the  stump,  leaving  nature  to 
complote  the  cure,  had  the  must  satisfactory  results. 
Experience,  however,  shows  the  process  of  cicatrization 
to  be  so  slow,  and  the  cicatrix  remains  so  long  sensi- 
tive, that  a  preferable  mode  is  to  amputate  in  healthy 
tissues,  at  some  little  distance  above  the  well-defined 
line  of  separation.  When  the  patient  is  in  good  health, 
or  bis  sj'stcm  has  been  prepared  by  good  food  and 
stimuli,  and  when  no  gastro-intestinal  complications 
are  engrafted  upon  the  local  injury,  this  secondary 
amputation  hastens  the  cure. 

It  may  be  necessary  to  modify  the  form  of  amputa- 
tion in  such  cases.  Where  the  toes  have  all  been  de- 
str03Ted,  the  line  of  mortification  is  usually  found  as 
extensive  in  the  sole  as  upon  the  back  of  the  foot,  which 
prevents  the  usual  flap  from  being  taken  from  the 
plantar  surface.  In  such  cases  it  is  better  to  perform 
the  circular  amputation,  making"  perpendicular  in- 
cisions on  the  sides  of  the  foot  to  facilitate  the  section 
of  the  bones;  and  as  the  bones  of  the  inner  side  oft  lie 
foot  are  much  more  extensive  than  those  of  the  outer 
side,  the  line  of  circular  incision  should  be  oblique,  to 
allow  of  a  greater  extent  of  soft  parts  on  the  inner 
side  of  the  foot.  It  is  not  necessary  to  follow  the  con- 
tour of  the  joints  in  making  these  amputations.  The 
much  simpler  plan  is  to  use  the  saw  rather  than  to 
disarticulate — which  is  at  all  times  a  tedious  and 
troublesome  operation,  especially  when,  with  the  mor- 
tification of  the  anterior  portion  of  the  foot,  the  lever 
is  destroyed,  which  assists  so  materially  in  exposing 


MALINGERING.  441 

the  articular  interspaces  for  the  passage  of  the  knife. 
General  treatment  must  not.  be  overlooked  in  frost- 
bite. It  is  a  depressed  system  which  predisposes  to 
the  affection,  and  which,  by  its  injurious  influence,  re- 
tards the  cure.  'The  internal  use  of  iron,  barks,  good 
food,  etc.,  will  be  necessary  in  most  cases. 


MALINGERING. 

In  closing  this  Manual,  experience  induces  mo  to 
offer  to  army  surgeons  a  few  suggestions  regarding  the 
frauds  daily  practised  upon  medical  officers  by  im- 
postors, who  feign  disease  to  escape  military  dut}r. 
Malingering,  or  the  feigning  of  disease,  has  ever  been, 
and  will  continue  to  be,  popular  with  soldiers,  irre- 
spective of  the  material  of  which  an  army  is  composed. 
Honesty  of  purpose  and  patriotic  motives  are  not  the 
only  incentives  to  enlistment,  even  against  such  an  in- 
vasion as  our  enemies  are  now  carrying  on  for  the 
destruction  of  all  our  most  sacred  and  cherished  rights. 

The  odium  heaped  upon  those  who  would  remain  at 
home,  has  forced  many  into  the  ranks  who  were  but 
little  disposed  to  give  up  their  comforts  and  their 
habitual  idleness  for  the  active  and  laborious  duties  of 
camp  lite.  Such  soldiers  are  always  ready  to  use  every 
subterfuge  for  escaping  from  what  is  irksome  and  dis- 
tasteful to  them;  and  as  complaints  of  indisposition 
offer  an  easy  release,  it  is  the  plan  usually  adopted. 
Moreover,  where  large  bounties  are  offered  for  enlist- 
ment, many  are  found  who  would  enlist,  obtain  the 
bounty,  and  a  suit  of  clothes,  and,  by  feigning  disease, 
successfully  impose  upon  their  medical  officers,  be  dis- 


U2  MAI.INCKIUN 

charged  from  service,  to  re-enlist  in  a  few  'lavs,  di- 
stances arc  known  in  which  this  coarse  has  been 
--fully  pursued  several  times  in  a  ahort  period. 
Hence  it  is  thai  the  study  of  feigned  diseases  bee 
an  important  branch  of  military  Burgery,  both  for  the 
protection  of  the  service  and  the  detection  of  frand. 
Unless  medical  officers  are  aware  of  impostors,  and  are 

always  on  the  alert  to  detect  and  punish  such  imposi- 
tions, the  service  suffers  seriously,  and  the  willing 
soldier  is  over-taxed  with  double  duty. 

Among  the  varieties  of  sickness  classified  as  ma- 
lingering, are  slight  indispositions  much  exaggerated  ; 
or  the  symptoms  of  disease  may  be  purely  fictitious, 
while  diseased  conditions,  such  as  ophthalmias,  ulcers, 
wounds,  etc.,  may  bo  either  intentionally  produced 
or  aggravated  by  the  malingerer. 

Greneral  experience  shows  that,  at  times,  one  may 
he  more  or  less  depressed,  with  uneasy,  nervous  feel- 
ings, foreboding  Bickness.  These  are  transient  con- 
ditions, depending,  perhaps,  upon  a  disturbed  diges- 
tion, and  will  disappear  spontaneously  at  the  end  of  a 
lew  hours,  having  us  in  our  accustomed  health.  Ig- 
norant or  infatuated  is  that  phj(|ician  who  believes 
medicine  n 38arv  for  every  Mich  temporary  indis- 
position, and  who  adopts  the  rule  of  prescribing  drugs 
for  every  person  who  presents  himself  for  treatment. 
This  constant  drugging  is  detrimental  to  the  service, 
in  making  oases,  and  diminishing  the  effective  si  rengt  h 
of  a  command,  while  it  squanders  mfdioines  which  are 
only  replaced  with  trouble  and  expense.  A  little 
moral  courage  on  the  part  of  the  medical  officer  to  re- 
fuse the  applicant  as  a  patient,  and  a  word  to  the 
commanding  officer  to  overlook  his  call  for  guard 
duty,  will  gain  him  the  confidence  and  the  rospect  of 
the  soldier.     The  surgeon  should  not  act  hastily  in  his 


MALINGERING.  443 

diagnosis,  but  should  pass  judgment  only  after  a  careful 
study  of  the  case;  for  it  is  hard  to  force  a  sick  man  to 
duty,  but,  on  the  other  hand,  feigned  diseases,  which 
escape  detection,  are  rewards  granted  to  fraud. 

Among  the  diseases  most  readily  and  frequently 
feigned,  are  pain,  rheumatism,  deafness,  impaired 
vision,  etc. ;  all  erf  these  are  as  difficult  of  detection  as 
their  simulation  is  easy,  and  hence  the  readiness  with 
which  such  complaints  are  feigned.  When  we  are 
called  upon  to  investigate  these  suspected  cases,  we 
must  carefully  weigh  the  moral  and  physical  condition 
of  the  patient — his  habits,  his  probable  motives,  with 
the  presence  or  absence  of  pathognomonic  symptoms. 
During  the  examination  we  mustniai'k  the  disposition 
of  such  malingerers  to  overact  their  part,  their  anxiety 
to  impress  us  with  the  reality  and  severity  of  their 
sufferings,  and  also  the  readiness  with  which  they  can 
be  led  on  to  acknowledge  the  presence  of  incompatible 
and  preposterous  symptoms. 

When  pain  is  feigned,  as  this  may  really  exist  as  a 
disease  without  external  manifestation,  it  is  the  most 
difficult  of  all  symptoms  to  detect.     By  close  observa- 
tion and  constant  watching  the  fraud  may  be  detect- 
ed, although  the  malingerer  may  continue  his  com- 
plaints until   he  attains  his  object— a  discharge  from 
the  service.     In  studying  out  this  imposition,  we  must 
examine  into  the  nature  and  cause  of  this  pain — its 
duration  and  intensity— its  character,  whether  fixed 
or  wandering,  whether  persistent,  remitting,  or  inter- 
mitting, und  whether  increased  or  diminished  by  pr< 
ore — for  no  part  can    be  exquisitely  sensitive   under 
pressure,  which  will  not  show  other  indications  of  lo- 
,;1|  trouble.     If  the  patient  complains  of  an  internal 
pain,  we  should  examine  whether  it  be  accompanied 


I  I  I  MAl.IM.riMNC. 

by  those  symptoms  which  it  is  impossible  to  assume, 
and  the  absence  of  which  would  lead  to  suspicion. 

Much  may  also  be  Learned  from  the  treatment  pur- 
sued. In  real  diseases  painful  remedies  will  not  bo 
objected  to,  while  in  the  feigned  a  decided  aversion  is 
shown  when  the  use  of  these  remedies  is  threatened. 
1  have  cured  a  pain  of  six  months'  standing  in  a  ma- 
lingerer by  the  use  of  the  actual  cautery,  and  the 
promise  that,  if  the  first  application  did  not  remove 
all  the  [tain,  a  second  would  most  certainly  effect  it 
Even  the  prospect  of  a  severe  application  on  the  fol- 
lowing day,  if  the  patient  does  not  feel  better,  has 
brought  its  fruit.  This,  however,  docs  not  always 
succeed,  as  malingerers  have  withstood  the  repeated 
application  of  the  most  powerful  remedies,  and  have 
confessed  their  imposition  only  after  exhausting  the 
resources  of  the  suspecting  surgeon,  or  after  obtain- 
ing their  dismissal.  A  simple  mode  of  testing  the 
sensitiveness  of  what  the  patient  complains  of  as  an 
intense  pain,  is  by  making  pressure  upon  the  part 
when  the  patient  sleeps.  Sleep,  in  itself,  may  lead  to 
detection — as  quiet,  placid  sleep  at  night,  with  intense 
pain  during  the  day,  without  loss  of  flesh  or  genera] 
i  in  pa  i  mi  en  t  of  the  digestive  organs,  are  a  combination 

which  belongs  to  no  known  disease. 

The   pains  complained  of  by  malingerers   usually 

assume   the  form  of   a  rheumatism,  which    withstands 

all  treatment.  Notwithstanding  the  Liberal  use  of 
remedies,  this  pain  continues  unmitigated-— the  pa- 
tient at  all   times  suffering  severely j  while  the  true 

disease  is  mostly  affected  by  changes  in  the  weather. 
Catechising  in  the  feigned  disease  will  readily  mislead 

the  patient  into  acknowledging  inconsistent  and  con- 
tradictory symptoms,  which,  in  many  eases,  will  lead 


MALINGERING.  445 

to  detection.  Intense  and  long-continued  pain  in  a 
joint  can  not  exist  as  an  isolated  symptom.  Walking 
with  a  stick,  which  patients,  think  necessary  to  influ- 
ence the  medical  officer,  is  an  expedient  common  to 
all  those  whose  indispositions  are  less  serious  than 
they  would  have  the  medical  officer  believe.  Being 
stunned  by  a  bomb  is  a  piece  of  good  fortune  to  many, 
who  prefer  hospital  life  to  the  exposures  and  priva- 
tions of  the  field  ;  and  as  long  as  the  war  lasts  there 
will  be  some  who  will  have  partially-paralyzed  limbs 
and  painful  spines  from  this  cause.  To  be  "  stung  by 
a  hung,"  and  be  demoralized,  is  a  condition  which  hos- 
pital surgeons  classify  among  the  most  intractable  of 
diseases. 

A  feigned  paralysis  of  the  arm — a  disease  at  times 

•assumed — can   be  readily   detected  during  sleep,    by 

tying  the  sound  arm  to  the  body  and  tickling  the  nose 

or  lips,  when  the  palsied  arm  will  innocently  move  to 

the  face  to  brush  away  the  offending  body. 

Deafness  comes  next  in  order  as  a  disease  difficult 
of  detection,  and,  therefore,  frequently  assumed. 
Those  familiar  with  this  disease  will  often  notice  a  pe- 
culiar manner,  which  belongs  to  such  only  as  have 
difficulty  in  hearing.  The  surgeon  must  exercise  his 
ingenuity  in  devising  means  for  exposing  the  imposi- 
tion. Among  these  would  be  making,  suddenly,  loud 
noises,  such  as  discharging  a  pistol  near  the  car  of  the 
unsuspecting  person!  Very  few  have  such  control 
over  themselves  as  to  withstand  this  trial,  although 
instances  are  known  where  impOStorfl  remained  un- 
moved, notwithstanding  this  tot.  Relating  a  conver- 
sation in  which  the  patient  is  deeply  interested^  and 
watching  Clandestinely  the  play  of  his  features,  will, 
at  times,  lead  to  detection. 

Chloroform  is  found    :i  valuable   aid   in    detecting 


146  MALINGERING. 

fraud  in  those  who  feign  being  dumb.  An  instance 
has  come  to  my  notice  of  a  malingerer  who  had  suc- 
ceeded  repeatedly  in  rinding  the  enrolling  officer. 
At  last,  coming  under  the  inspection  of  one  alive  to 
the  frauds  practised  upon  conscripting  officers,  chloro- 
form was  administered,  when,  under  its  intoxicating 
influence,  Ins  tongue  soon  became  loose,  to  the  aston- 
ishment of  his  wife,  who  had  not  heard  the  sound  of 
hi  8  voice  for  several  years.  The  loss  of  voice,  when 
the  effects  of  chloroform  had  passed  off,  was  readily 
restored  under  the  bucking  process — this  severe  treat- 
ment establishing  a  complete  and  permanent  cure. 

Like  impairment  in  hearing,  so  is  impaired  sight  a 
very  common  complaint  among  those  who  desire  to 
escape  duty.  Night  or  day  blindness  is  a  complaint 
which  may  have  foundation  under  certain  eireum-  • 
stances,  but  is  rarely  met  with.  When  suspicion  is 
aroused,  compulsoiy  duty  is  the  best  remedy.  Un- 
der the  plea  that,  for  sentinel  duty,  and  especially  for 
night  duty,  hearing  is  even  more  important  than  Boe- 
ing— and  as  four  ears  are  always  better  than  two — a 
double  guard,  of  which  the  malingerer  is  one.  should 
be  placed  at  the  post.  At  the  same  time,  a  low  diet 
will  show  the  impostor  that  his  complainl  does  nol 
meet  with  much  sympathy.  A  soldier  may  appear 
before  the  medical  officer  with  an  excessively  dilated 
pupil,  and  with  a  complaint  of  impaired  vision.  It 
must  be  remembered  that,  as' a  disease,  this  symptom 
seldom  appears  alone,  and  that  a  drop  of  a  solution  of 
bolladonna  will,  at  any  time,  induce  it.  Where  such  a 
case  excites  suspicion,  searching  the  patient  and  lock- 
ing him  up,  under  guard,  will,  in  a  few  days,  solve  the 
doubts  by  the  return  of  the  pupil  to  its  normal  dimen- 
sions. 

Epilepsy  is  another  disease   ofti  d  attempted.     To 


MALINGERING.  447 

have  fits  is  thought  by  the  public  to  be  the  acme  of  an 
incurable  condition,  deserving  the  commiseration  of  a 
community;  and  the  soldier  necessarily  infers  that  a 
man  who  can  have  a  fit  while  in  camp,  surrounded  by 
his  companions,  may  have  a  similar  one  while  on  guard 
duty,  and  is,  therefore,  not  a  proper  person  to  be  en- 
trusted   with  the  protection  of  a  camp.     These  fits 
are  brought  on  at  will.     Should  the  surgeon  of  a  hos- 
pital  express  a  desire,  in  the  hearing  of  the  patient, 
to    see  him  during  an  attack,  he  will  most  likely  be 
accommodated  during  the  day.    This  disease  has  been 
so   frequently  feigned,  both  in  civil  as  well  as   mili- 
tary life,  and  the  symptoms  of  the  disease  have  been 
so    carefully  studied,  that  mo,st  surgeons  will   be  on 
their  guard  against  such  impostors.     A  drop  of  tur- 
pentine or  alcohol  in  the  eye  of  such  an  one  will,  with- 
out doing  harm,  bring  his  acting  to  a  speedy  close. 
Very  tew  impostors  can  stand  this  innocent  test.     It 
is,  perhaps,  as  well  to  state  that,  during  the  epileptic 
fit,  all   sensibility  is  for  the  time  suspended,  which  is 
not  the  case,  of  course,  when  the  disease  is  feigned. 

A  feverish  skin  may  also  be  simulated  by  the  liberal 
use  of  a  flesh  brush,  while  the  foulest  coat  upon  the 
tongue  can  be  manufactured  at  will  by  a  local  applica- 
tion of  chalk,  clay,  ashes,  brick-dust,  flour,  soap,  etc. 
Deformities  and  contortions  of  the  limbs,  which  are 
never  drawn  up  during  sleep,  or  under  the  influence  of 
chloroform,  are  also  feigned  by  malingerers,  and  will 
require  the  most  careful  scrutiny.  In  order  to  deceive, 
the  mouth  is  scarified  to  permit  the  spitting  of  blood, 
ulcerations  on  the  legs  are  made  by  the  pressure  of 
bard  substances,  and  swollen  arms  and  legs  by  ligating 

the  extremities  near  the  trunk.      Frequent  micturition 

or  diarrhoea  may  easily  be  complained  of,  and  dysen- 
t.  ri<    Btoola  have  been  actually  stolen  from  neighboring 


448  MALINGERING. 

patients  to  assist  in  carrying  out  the  deception.  It  is 
only  necessary  for  surgeons  to  know  to  what  extent 
diseases  may  be  feigned,  to  be  prepared  to  meet  the 
impostors;  and  by  using  all  the  means,  both  morally 
ami  medically,  which  their  ingenuity  would  suggest,  to 
detect  and  punish  the  malingerer. 

Maiming,  or  self-mutilation,  is  occasionally  practised 
in  every  army  by  craven,  cowardly  men,  who,  in  this 
way,  try  to  escape  the  dangers  or  privations  of  the 
field.  In  the  English  service  every  soldier  maimed  by 
the  discharge  of  his  own  musket,  and  who  thereby  bo- 
comes  unfit  for  service,  whether  the  injury  occurred 
on  or  off  duty,  or  whether  accidental  or  intentional,  is, 
in  evciy  case,  tried  by  a,  distinct  court-martial  as  soon 
after  the  event  as  possihle.  The  soldier's  claim  to  a 
discharge,  or  even  his  exemption  from  punishment, 
will  depend  upon  the  decision  of  the  court. 


APPENDIX. 


Li, 


A  FEW  PRACTICAL  RULES  USEFUL  IN  PERFORM- 
ING THE  VARIOUS  OPERATIONS  REQUIRED  IN 
MILITARY  SURGERY. 


AMPUTATION  OF  THE  FINGER. 


Owing  to  the  size  of  the  phalangeal  bones  composing  the  fiuger 
(plate  2,  fig.  1),  amputations  are  usually  performed  in  the  joints  for 
any  injury  which  the  bones  may  have  sustained,  although,  under  cer- 
tain circumstances,  it  may  be  preferable,  when  a  good  flap  can  be 
made  from  the  soft  parts  around  the  wound,  to  remove  the  finger  at 
the  point  of  injury,  cutting  off  the  sharp  ends  of  the  bone  with  a  bone 
forceps.  This  proceeding  gives  an  equally  good  result  with  disarticu- 
lation. In  gunshot  wounds  of  the  fingers,  as  the  bone  as  well  as  soft 
parts  are  usually  much  crushed  by  the  missile,  disarticulations  through 
the  joint  above  the  injury  arc  to  be  preferred. 

In  examining  fig.  1,  of  plate  2,  it  will  be  seen  that  the  phalangeal 
bones  have  their  extremities  enlarged,  but,  at  the  same  time,  so  round- 
ed off  that  when  brought  in  contact  with  each  other  a  ring  of  depres- 
sion exists  at  the  point  of  apposition.  The  lateral  surfaces  of  these 
enlarged  heads  are  roughened  and  nodulated  for  the  attachment  of  the 
lateral  ligaments  of  the  joint.  These  are  so  proiniuent,  that  when  the 
index  finger  and  thumb  of  the  surgeon  are  made  to  glide  with  pressure 
over  the  lateral  surfaces  of  a  finger  from  its  extremity  upward,  the 
contracted  shaft  of  the  phalangeal  bone  is  felt  enlarging  as  the  joint 
is  approached.  Surmounting  the  first  elevation  is  a  line  of  depression, 
followed  immediately  by  a  second  elevation,  from  which  the  fingers 
gradually  descend  upon  the  constricted  shaft  of  the  superimposed 
phalanx.  Between  the  two  hillocks  is  the  depressed  line  of  the  articu- 
lation. Another  mode  of  determining  the  articulating  surface  is  by 
traction  upon  the  inferior  portion  of  the  finger — when,  the  ends  of  the 
bones  being  drawn  apart,  the  surgeon  can  insert  the  nail  of  his  index 
finger  between  the  separated  articulating  ends  ot^tho  dorsal  surface  of 
the  finder.  If  much  delay  has  occurred,  however,  i"  the  presentation 
of  the  wounded  loldier,  the  finger  may  have  become  so  much  swollen 
M  to  have  obaoarod  these  prominences  end  depn  lions.  The  natural 
folds  upon   the  palmar  face  of  tho  fuigrr  c;i]i  alwayi   be  I 


152  A.Mii  TATION    OF   A    PHALANX. 

fnllible  guide  to  the  position  of  tin-  :irticulating  surfaces — plate  '.'. 
and  2.  Of  the  three  folds,  the  middle  one  corre*pond«  alwayt  with  the 
junction  of  the  oral  and  second  phalanges]  bones.  The  Fold  nearest  the 
end  of  the  finger  lies  one-eighth  of  an  inch  behind  the  joint  of  tin- 
second  and  third  phalanges,  while  the  upper  fold  lies  half  an  inch  in 
front  of  the  articulation  of  the  Anger  with  the  palm  •if  the  hand.  If  it 
he  remembered,  in  connection  with  these  landmarks,  that   when  any  of 

the  hinge-joints  are  Hexed  at  right  angles,  the  antcro-posterior  diame- 
ter lit  the  lower  head  of  the  upper  bone  forms  tlie  prominent  angle,  and, 
it  allowances  be  made  for  its  width,  the  articulating  surfaces  anterior  to 
it  will  be  readily  found.  In  performing  amputations  of  the  fingers, 
the  sharp-pointed  bistoury,  found  in  all  pocket-eases  of  instrument", 
is  the  knife  preferred. 

Amputation  of  a  part  of  a  FiNniiR. — In  amputating  at  the  sec- 
ond or  third  phalangeal  articulation,  either  the  circular  or  flap  operation 
may  be  used,  and  the  latter  either  by  transfixion  <>r  by  cutting  the 
flaps  from  without.  The  plan  generally  adopted  is  thai  of  making  an 
anterior  Hap  from  the  palmar  surface,  as  in  plate  2,  fig.  5,  by  trans- 
fixing, with  a  sharp-pointed  bistoury,  the  finger  on  a  level  with  the 
articulation,  including  in  the  (lap  about  being  formed  half  the  soft  parts 
comprising  the  finger.  'Ibis  is  accomplished  by  entering  the  point  of 
the  knife  from  the  side  of  the  finger  in  such  a  way  as  to  strike  the 
lateral  surface  of  the  phalanx;  the  handle  being  now  depressed, 
allows  the  point  to  glide  over  the  bone,  when  it  should  be  in  turn  ele- 
vated so  that  the  point  will  protrude  opposite  to  its  place  of  entrance. 
The  blade  is  now,  by  a  sawing  motion,  made  to  graze  the  bono  in  its 
descent  for  the  distance  ■  I  ball  or  three  quarters  of  an  inch,  when  the 
blade  is  made  t"  cut  dinctl\  out  at  right  angles  to  its  former  course, 
which  completes  the  Hap.  The  bund  is  now  turned  over  to  its  dorsal 
as]. cct,  and  the  skin  of  the  linger  upon  which  the  amputation  is  being 
performed  being  well  drawn  upward  by  an  assistant,  the  position  of  the. 
joint  having  been  satisfactorily  located,  an  incision  is  made  at  right 
angles  to  the  flap,  which  will  join  the  incisions  on  each  side  of  the  fin- 
ger, a*id,  ut  the  same  time,  expose  the  articulation.  The  lateral  liga- 
ments form  the  key  to  the  joint,  and  keep  the  extremities  of  the  pha- 
langes in  close  apposition.  Until  these  arc  divided,  which  should  be 
effected  by  the  point  of  the  knife,  the  articulation  can  not  he  traversed. 

This  amputation  may  be  modified  in  the  following  way:  After  mak- 
ing the  palmar  flap,  this  might  be  raised  bj  an  assistant  (plate  11,  fig. 
6),  and  the  joint  entered  from  the  palmar  surface.  Unless  the  operator 
is  well  skilled  in  anatomy  and  in  the  operative  manual,  the  articulation 
will  not  be  easily  found,  as  the  configuration  of  the  parts  will  most  proba- 
bly throw  I  he  knife  above  the  joint  upon  the  shall  of  the  superior  jdia- 


AMPUTATION    OF    A    FINGER.  453 

lanx.  The  steps  of  this  amputation  may  be  reversed — the  articulation^n- 
tered  from  the  dorsal  surface,  as  seen  in  plate  2,  fig.  3,  and,  after  the 
division  of  the  dorsal  and  lateral  ligaments,  the  finger  being  bent,  the 
blade  traverses  the  joint,  and  then  has  its  position  changed  to  one  of 
right  angles  to  its  former  course — fig.  4.  The  finger  is  now  extended, 
and  the  palmar  flap  cut  as  before  directed.  The  arteries  being  very  small, 
do  not  require/  usually,  a  ligature;  twisting  them  with  a  torsion  forceps 
will,  as  a  rule,  prevent  hemorrhage.  Should  they  bleed,  however,  they 
should  be  ligated.  The  flap,  which  should  be  made  always  long  enough 
to  cover  completely  the  exposed  articulating  surface,  will  be  adjusted 
by  two  or  three  points  of  suture,  and  the  application  of  a  single  thick- 
ness of  wet  cloth  completes  the  dressing.  The  adhesive  plaster  dressing, 
which  was  the  old  method  of  putting  up  stumps  before  water  dressing 
came  into  vogue,  would,  when  wet,  become  detached,  and  permit  the 
wound  to  gape,  which,  in  itself,  would  destroy  all  hope  of  union  by  the 
first  intention.  The  sutures  should  be  removed  on  the  fifth  day.  The 
wet  cloth  will  be  continued  for  a  few  days  longer,  when  simple  cerate 
dressing  should  be  substituted.  All  the  advantages  of  cold  water  dress- 
ing, which  are  chiefly  to  prevent  inflammation  and  promote  quick 
union,  will  be  obtained  within  ten  days,  when  its  use  should  be  dis- 
continued. When  used  it  should  be  applied  to  the  stump  alone,  and 
not  to  the  entire  extremity.  Cold  water  dressing,  although  essential 
in  the  treatment  of  wounds,  like  every  good  remedy,  is  liable  to  much 
abuse.  Its  diffused  application,  and  the  extravagant  waste  of  cloth, 
extending  over  an  entire  limb  for  a  circumscribed  wound,  can  not  be 
too  severely  ojxiticised. 

During  the  inflammatory  stage  of  reaction,  extending  over  the  first 
five  or  six  days  succeeding  an  amputation,  cold  water  should  be  freely 
used  ;  but  when  this  period  has  passed,  a  damp  cloth,  renewed  before  it 
becomes  dry,  is  the  proper  dressing:  otherwise,  an  inflammation  of  the 
skin  is  set  up,  with  the  formation  of  itching  pustules,  which  are  more  an- 
noying to  the  patient  than  the  wound  for  which  the  water  treatment 
is  used. 

Amittation  of  a  Finger. — In  removing  an  entire  finger  at  the  mcta- 
carpo-phalangeal  articulation,  one  of  two  methods  are  usually  adopted: 
either  by  the  oval  method,  or  by  lateral  flaps — plate  2,  fig.  7.  The 
urticulating  surface  will  be  located  as  directed  above  for  the  ]>balangeal 
joints,  but  more  especially  by  traction  upon  the  finger,  which  v 
ar&te  the  extremities  of  the  bones  to  a  considerable  t  stent.  The  in- 
cision must  be  commenced  upon  the  back  of  the  hand,  over  and  ujiun 
the  metacarpal  bone,  and  at  least  half  an  inch  above  its  inferior  ex- 
tremity. This  is  continued  parallel  with  the  bone  until  it  reaches  tho 
articulation,  when   ilt    direction  is  obliquely  changed,  puling  midway 


454  AMPUTATION    OF   ALL   THE    FINGERS 

D  the  fingers  to  the  extremity  of  the  webbed  portion  of  skin.  II 
the  oval  method  has  been  Selected,  the  knife  is  now  made  to  encircle  the 
palmar  face  of  the  finger  in  the  upper  Fold  of  skin  indicating  the  junc- 
tion "f  the  finger  and  hand,  and  is  then  brought  up  upon  the  opposite 
side  of  the  finger;  when  reaching  the  web  of  skin  its  direction  is  changed 
to  make  an  oblique  incision  similar  to  the  one  first  traced,  and  which 
will  meet  this  on  a  level  with  the  joint — not,  therefore,  where  the  in- 
cision started  from,  Imt  half  an  iuch  below  it  If  the  incision  was  con- 
tinued upwards  to  end  where  it  was  commenced,  a  V  flap  of  skin  would 
be  removed,  which  would  leave  a  deficiency  of  soft  parts  for  covering 
the  exposed  end  of  the  metacarpal  bone. 

If  the  flap  operation  has  been  preferred,  the  direction  of  the  knifo  is 
changed  after  reaching  the  webbed  portion  of  skin  before  spoken  of,  and 
instead  of  encircling  the  palmar  surface  of  the  finger,  it  follows  an  oblique 
course  in  the  palm  corresponding  to  and  directly  under  the  oblique 
dorsal  incision.  When  the  point  of  the  knife  roaches  the  palmar  site  of 
the  joint,  which  will  make  an  incision  three-quarters  of  an  inch  in  length 
and  terminating  one-third  of  an  inch  from  the  transverse  fold  in  the 
palm  of  the  hand,  its  direction  is  changed,  so  as  in  cutting  out  to  mnke 
an  equally  oblique  incision,  passing  through  the  webbed  skin  upon  the 
opposite  side  of  the  finger  to  bo  amputated,  and  continuing  obliquely 
upon  the  back  of  the  hand  to  meet  the  first  incision  over  the  articulat- 
ing surface. 

The  flaps  are  now  dissected  upward,  in  order  to  isolato  them  from  the 
finger,  which  is  drawn  upon  and  flexed  at  right  angles,  so  as  to  facilitate 
the  disarticulation,  which  can  now  be  readily  effected  by  dividing  the 
r  tendon  and  dorsal  ligament,  then  the  lateral  ligaments  which 
form  the  key  to  the  joint,  and  finally  the  palmar  ligament  with  flexor 
tendons.  In  all  hinge  joints  the  bones  are  kept  in  close  apposition  by 
these  lateral  ligaments,  and  to  facilitate  their  division  it  is  necessary 
to  put  them  upon  the  stretch  by  flexing  tho  bone  laterally.  The  two 
small  arteries  which  run  parallel  on  either  side  of  the  head  of  the  meta- 
carpal bone  will  require  ligation,  otherwise  annoying  hemorrhage  will 
probably  occur,  necessitating  tho  opening  of  the  stump.  To  avoid  com- 
plicating the  wound  with  too  many  foreign  bodies,  one  end  of  tho  liga- 
ture should  be  cut  off  near  the  knot,  and  the  other,  drawn  out  from  tho 
most  convenient  portion  of  the  wound,  la  confined  about  one  inch  above 
the  stump,  under  a  strip  of  adhesive  plaster.  Thrco  or  four  stitches  will 
keep  the  flaps  in  close  apposition,  and  a  single  thickness  of  wet  cloth 
completes  the  dressing. 

Amputation  ok  all  thk  Fingkrs. — When  a  gunshot  wound  has  so 
crushed  all  of  the  fingers  as  to  necessitate  the  removal  of  all  of  them, 
the  flap  to  cover  the  heads  of  the  metacarpal  bones  must  be  made  from 


AMPUTATION    OF    METACARPAL    BONE.  455 

tho  palm,  and  also  a  small  flap  from  the  dorsal  skin  to  assist  in  covering 
over  these  large  bones.  Tho  site  of  the  articulations  being  readily  de- 
termined, the  operator  commences  the  palmar  incision,  if  he  is  operating 
upon  the  right  hand,  by  inserting  the  point  of  the  knife  through  tho 
skin  upon  the  lateral  surface  of  the  joint  of  the  index  finger,  midway 
between  the  palmar  fold  and  the  fold  at  the  base  of  the  finger.  From 
this  point  he  traces  a  curved  incision  across  the  junction  of  the  fingers 
with  the  palm,  extending  to  a  similar  point  upon  the  outer  side  of  the 
little  finger,  having  traversed  the  palm  one  line  above  the  intcrdigital 
web.  The  object,  at  this  step  of  the  amputation,  being  simply  to  trace 
out  the  form  of  the  flap,  the  knife  only  traverses  the  thickness  of  the 
skin. 

The  hand  is  now  reversed;  and  while  an  assistant  retracts  the  skin, 
as  seen  in  plate  3,  fig.  2,  a  similar  incision  is  marked  out  on  the  dor- 
sal surface,  extending  also  in  an  elliptic  form  from  the  outer  to  the  in- 
ner termini  of  the  palmar  flap,  and  from  one-fourth  to  one-third  of  an 
inch  below  tho  joints — which  is  as  deep  as  a  regularly  delineated  flap 
can  be  made,  owing  to  the  skin  dipping  down  between  tho  fingers. 
This  anterior  flap,  which  is  the  least  vascular,  is  now  rapidly  dissected 
up,  the  joints  opened  from  their  dorsal  surface,  the  long-bladed  knife 
passed  through  and  under  them,  and  a  flap  cut  out,  following  the  line 
which  was  marked  out  in  the  palm.  The  arteries  having  been  ligated 
as  they  are  exposed  between  each  metacarpal  bone,  the  flaps  are 
brought  together  by  means  of  five  or  six  points  of  suture,  which,  by 
their  nice  adjustment,  will  give  an  excellent  result. 

The  assistant  who  holds  the  hand  for  the  surgeon  can  assist  materi- 
ally in  the  successful  accomplishment  of  the  amputation  by  handling 
the  limb  in  the  following  manner:  The  hand  to  be  operated  upon  be- 
ing pronatcd  with  the  dorsal  surface  upwards,  the  assistant  places  his 
two  hands  on  each  side,  with  the  ends  of  the  second,  third,  and  fourth 
fingers  of  each  hand  resting  over  the  course  of  and  compressing  the 
radial  and  ulgar  vessels ;  the  patient's  wrist  is  clasped  by  the  balls  of  the 
assistant's  thumbs — which  are  the  supporting  power  upon  the  back  of 
the  wrist,  and  against  which  pressure  is  made  by  the  fingers  resting  over 
the  arteries.  The  two  index  fingers  make  tense  the  skin  of  the  palm  of 
the  hand,  while  the  thumbs  of  the  assistant  make  traction  upon  the 
skin  of  the  dorsal  surface,  which  enables  the  surgeon  to  include  all  the 
skin  possible  in  the  posterior  flap.  Without  shifting  his  grasp  the  as- 
sistant can  pronate  or  supinate  the  hand  as  the  surgeon  requires,  in  the 
various  steps  of  the  amputation.  This  is  a  good  method  of  securing 
the  hand  during  all  operations  upon  this  extremity. 

Amputation  ok  Fin<;i,k.  with  METACARPAL  Hose. — When  neces- 
sary to  remove  a  port  ion  of,  or  the  entire  metacarpal  I ,  similar  meth- 


1  .'•'*•  AMPUTATION    01    MKTACARPAL   BONE. 

ode  of  operation  may  be  adopted  ta  In  the  removal  of  n  finger,  selecting 
either   the  ovol   method,   0*  lateral   flap,   according   to   the  character  of 

the  injury  or  the  faney  of  the  surgeon.  Plate  2.  fig.  8,  Indioatee 
how  the  oral  method  should  be  6arried  oot  When  the  entire  An 
quires  remoTal,  the  point  of  the  knife  ihonld  eommenee  to  traoe  (he  inci- 
sion oreT  the  carpal  bone  to  which  the  finger  is  attached.  For  the  thumb 
the  incision,  soanmencing  over  and  npon  t hi-  trapezium  bone, 
donnmurdl  npon  ami  ]>arallel  with  the  metacarpal  hone  for  half  its 
length,  when  its  direction  if  changed  obtf ojucly,  so  as  to  pass  around 
the  finger,  as  in  plate  2.  fig.  B.  When  the  soft  parts  arc  separated 
from  the  bona,  an  in  plate  2,  fig.  9,  the  thumb  is  forcibly  Hexed  into 
the  palm,  which  makes  prominent  the  head  of  the  bone  and  stretches 
the  ligaments  With  the  point  of  the  knife  both  the  posterior  and  lat- 
eral ligaments  are  divided,  which  allows  the  bone  to  be  lifted  up,  the 
knife  passed  under  it.  and  the  finger  detached.  The  stump  is  well 
shown  in  plate  2,  fig.  10. 

The  only  difference  between  removing  one  of  the  middle  fingers,  or 
with  it  the  metacarpal  hone  in  part  or  in  whole,  is  in  the  length  of  the 
perpendicular  inoiaion.  In  the  Bap  operation,  which  is  preferred  by 
many  for  the  little  finger  or  thumb,  the  lateral  Bap  ii  defined  by  plan* 
inL'  the  point  of  the  knife  (plate  •"•.  fig.  Ii  over  the  articulation  of  the 
oarpne  with  the  metacarpal   bone  on  the  back  of  the  band,  tracing  an 

incision  npon  and  parallel  with  the  metacarpal  bone  over  itl  entire 
length.  \\  hen  it  has  passed  the  level  of  the  metacarpo-digital  articu- 
lation it  turns  off  obliquely  to  the  outer  Bide  of  the  finger,  continuing 
downward!  to  the  middle  of  the  first  phalanx,  or  to  a  level  with  the  ex- 
tremity of  the  interdigital  web;  the  point  of  the  knife  is  then  reversed, 

und   an    incision,  Cones] ling  exactly   to  that   upon    the  back  of  the 

hand,  is  traced    in   the  palm.     In  these   lines  a  broad  outer   flap  is  dis- 

Bectod  up. 

The  skin  of  the  hand  being  DOW  drawn  inwards  by  an  assistant,  the 
knife,  with  its  edge  against  the  web,  is  placed  between  the  linger  to  bo 
operated  upon  nnd  its  neighbor,  and.  by  a  .-awing  movement,  is  made 
t0  traverse  fn  ■  below  upwards,  the  intermetacarpal  space  meeting  the 
first  incisions  where  the  metacarpal    hone  joins  the  carpus.      The  linger 

is  now  forcibly  drawn  outward,  which  puts  the  carpo-metacarpal  liga- 
ments upon  the' stretch,  and  facilitate!  their  division  from  within  out- 
wards. When  the  load  of  the  bone  is  liberated  the  knife  is  passed  upon 
its  ■.uter  side,  and,  by  cutting  from  above  downwards,  the  Boft  pu 

severed  from  the  metacarpal  bone  in  the  lines  of  incision,  and  the  llap 
completed.  When  the  arteries  are  ligated  and  the  flap  socured  in  its 
position  by  several  points  of  suture,  very  little  deformity  will  be  ob- 
bi  1-.  ed. 


PARTIAL    AMPUTATION    OF    HAND.  457 

AMPUTATION  OF  THE  HAND. 

Partial  AMPUTATION  of  hand. — In  injuries  to  the  hand  the  surgeon 
must  ever  remember  that  every  portion  of  this  extremity  which  can  be 
saved  ean  be  made  useful  ;  and  the  thumb  alone,  when  opposed  to  oven 
a  portion  of  the  palmar  surface,  will  prove  far  more  useful  than  tho 
most  elaborate  artificial  limb.  Therefore,  should  tho  hand  bo  over  so 
much  crushed  by  shell  or  shot,  if  the  thumb  and  one  or  more  fingers 
cau  be  retained,  it  is  the  duty  of  the  surgeon  so  to  improvise  an  opera- 
tion as  to  remove  only  those  portions  which  extended  experience  has 
shown  can  not  be  saved.  Experience  has  established  the  fact  that 
frightful  mutilations  arc  not  incompatible  with  the  restoration  of  a  use- 
ful member;  therefore  we  must  not  be  guided  by  appearances  in  con- 
demning a  hand.  If  two  or  three  fingers,  with  thoir  metacarpal  bones, 
have  been  crushed,  with  soft  parts  torn,  and  bones  protruding,  sueh 
fingers  alone  should  be  amputatod.  If  all  the  metacarpal  bones  of  the 
palm  have  been  crushed,  with  frightful  laceration  of  tho  soft  parts,  it 
may  still  be  possible  to  saw  through  the  metacarpal  bones  immediately 
above  their  broken,  spiculated  surfaces,  which  is  a  better  operation,  when 
we  have  the  choice,  than  disarticulating  in  the  carpo-mctacarpal  joint — 
plate  3,  fig.  5.  In  performing  this  amputation  the  flap  is  made,  as 
usual,  from  the  palmar  surface,*  either  by  marking  with  the  point  of  tho 
knife  the  form  and  size  of  the  flap  desired,  and  then  dissecting  it  from 
without  inwards,  or,  having  mapped  out  its  extent,  cutting  it  up  rapidly 
by  transfixion — plate  3,  fig.  6. 

In  amputating  the  right  hand,  the  point  of  the  knife  perforates  over 
the  unciform  bone,  and,  after  traversing  the  entire  palm,  appears  at  the 
root  of  the  thumb  at  a  point  where  its  web  joins  tho  lateral  surfaco 
of  the  hand.  'With  a  sawing  motion  the  heel  of  the  knife  cuts  out  the 
flap  by  following  the  line  which  had  been  previously  traced,  c  ba,  in  plate 
3,  fig.  6.  The  hand  is  then  reversed  (figure  5)  and  an  incision  made 
on  a  level  with  the  oarpo-metaoarpal  joint,  extending  on  the  back  of  tho 
band  from  its  outer  border  to  the  head  of  the  metacarpal  bone  of  the 
thumb,  "  to  6 — then  obliquely  downwards  through  the  interspace  b  c, 
between  the  metacarpal  bones  of  the  thumb  and  index  finger,  to  meet 
the  commencement  ol  the  palmar  incision.  Th#hand  is  thcti  forcibly 
Bexed,  the  point  of  the  knife  dividing  the  posterior  carpal  ligaments  and 
Opening  the  joints,  the  line  of  which  can  bo  determined  by  per  land- 
marks—one, the  head  of  the  metacarpal  bone  of  the  thumb,  and  the  other 
the  prominence  of  the  cuneiform  bone  on  the  outer  border  of  th<'  band; 
•  low  this  prominence  is  the  articulation  of  the  fourth  and  fifth 
with  the  unciform  bone  of  the  carpus.  Af-  the  large 
supplying  the  hand  run  through  the  palm,  the  low  of  much  blood 
during  the  amputation  can  be  aroidt  d  by  making  f>  erii  r  In- 


458  AMPUTATION    AT    THE    WRIST-JOINT. 

cisions,  then  completing  the  division  of  the  ligaments,  and  opening  the 
joint  before  the  palmar  flap  is  dissected  up.  Complete  the  operation  by 
ligating  every  bleeding  vessel,  ami  retain  the  flap  in  thorough  apposi- 
tion by  using  a  sufficient  number  of  sutures. 

Ampvtation  at  tiik  wrist-joint. — The  hand  is,  however.  BO  muti- 
lated at  times,  from  the  effect  of  shot  or  shell  H  onnds,  that  it  is  impi 
ble  to  save  it,  and  its  entire  removal  is  demanded.  Under  such  cirr 
cumstances  disarticulation  at  the  radio-carpal  joint  may  l>e  performed, 
either  by  dissecting  up  a  circular  flap  of  skin,  or  b}-  making  a  palmar 
flap.  Commencing  the  circular  incision  an  inch  below  the  styloid  proc- 
esses of  the  radius  and  ulna,  which  form  easily-felt  prominences  on 
each  side  of  the  wrist-joint,  dissecting  up  the  skin  alone,  a  flap  is 
made,  which  is  turned  up  over  the  lower  part  of  the  arm  as  the  cuff  to 
a  sleeve.  When  dissected  up  to  the  level  of  the  joint,  which  is  rccog- 
•  nized  by  the  styloid  processes,  the  tendons  on  the  back  of  the  hand  are 
divided  by  a  sawing  motion  of  the  knife,  also  tin-  capsule,  which,  is 
very  thin,  and  the  joint  is  thus  opened  from  behind.  The  division  of 
the  lateral  ligaments  and  flexor  tendons  complete  the  operation.  The 
prominent  ends  of  the  radius  and  ulna  should  be  removed  with  the  saw 
before  the  flap  is  closed  by  suture;  as,  otherwise,  these  projections  of 
bono,  compressing  the  sensitive  skin  of  the  flap,  leave  >'>ro  points  for 
some  time  after  the  wound  has  complete!]  cicatrized, or, by  their  pi 
urc,  may  cause  ulceration  through  the  skin.  The  radial  and  ulnar 
arteries,  which  will  require  ligation  after  this  amputation,  will  be  found 
on  the  outer  and  upper  sides  of  their  respective  bones. 

The  flap  operation  which  gives  the  most  perfect  adaptation  of  the 
soft  parts  over  the  ends  of  the  bones,  is  performed  as  follows  :  With  tho 
palm  of  the  hand  upwards,  the  point  of  the  knife  is  made  to  perforate 
the  skin  on  the  lateral  surface  of  the  band  immediately  tinder  tho  sty- 
loid process  of  the  radius;  from  which  point  (plate  3,  fig.  v  i  an  inci- 
sion descends  for  three-quarters  of  an  inch,  then  sweeps  n  a  semicircu- 
lar diroction  across  the  palm  one  and  a  half  inches  be  ow  the  joint, 
to  terminate  in  a  perpendicular  incision  of   three-quarters  of   an  inch 

under    tho   styloid  process   of  tho  ulna.     Tho  styloid    pi ss  of  the 

radius  is  felt  as  a  pro#incnce  on  the  outer  side  of  the  wri  t-joint  and 
continuous  with  the  shaft  of  the  radius,  the  styloid  process  of  tho  ulna 
being  on  the  inner  side  and  continuous  with  the  ulna  bone.  A  slightlv 
concave  incision  (concavity  looking  toward  the  hand),  into  which 
the  convexity  of  the  palmar  flap  will  bo  nicely  adjusted,  is  now  made 
over  the  back  of  the  joint  (plate  3,  fig.  8),  connecting  the  styloid 
incisions.  With  a  sawing  movement  of  the  knife  the  tendous  on,  the 
back  of  the  hand  are  divided,  and  the  articulation  widely  opened.  The 
lateral  ligaments  being  sovcrcd,  the  amputation  is  completed  by  push- 


AMPUTATION    OF    THE    FOREARM.  450 

ing  the  blade  of  The  knife  through  the  joint  and  under  the  honey,  when 
a  palmar  flap  is  dissoctod  out  in  the  line  of  incision  previously  traced. 


AMPUTATION  OF  THE  "FOREARM. 

Several,  methods  of  amputating  the  arm  may  be  adopted  where  tbo 
radius  and  ulna  have  been  crushed,  with  extensive  injurjr  of  the  soft 
parts,  viz:  the  circular  amputation,  a  double  flap,  or  a  long  anterior 
flap,  sufficient  to  form  a  good  stump — the  rule  in  this,  as  in  all  amputa- 
tions, being  to  leave  the  greatest  length  of  limb  possible. 

Circular  method. — Although  the  circular  amputation  can  be  applied 
to  every  portion  of  both  extremities,  thero  are  certain  portions  of  the 
limb  where  other  methods_are  preferable.  Such  is  the  case  where  an 
amputation  is  demanded  upon  the  lower  portion  of  the  arm,  where,  the 
limb  being  conical,  the  lower  border  of  the  flap  is  everted  over  the 
larger  portion  of  the  limb.  As  the  skin  is,  however,  very  elastic,  this 
can  be  effected  withoutmuch  effort.  A  circular  incision  is  made  around 
the  arm,  extending  alone  through  the  skin  (plate  5,  fig.  2) — the  object 
being  to  avoid  injuring  the  deep  vessels  of  the  limb  at  this  stage  of  the 
amputation,  and  thus  save  the  patient  the  loss  of  blood  which  he  would 
otherwise  incur.  This  skin  is  then  dissected  up  from  the  muscles,  and, 
when  separated  sufficiently,  is  turned  over  as  the  cuff  of  a  coat  would 
be,  when  its  isolation  can  be  the  more  readily  effected  by  drawing 
the  sharp  edge  of  tho  knife  upon  the  bands  of  cellular  tissue  which 
tie  down  the  *kin  to  the  deeper  tissues,  until  a  sufficiency  of  flap  is  ob- 
tained. The  incision  through  tho  skin  is  always  located  in  reference 
to  the  point  where  it  is  desired  to  divide  the  bones,  the  proper  allow- 
ance being  made  for  tho  size  of  the  limb.  If  the  limb  is  to  be  removed 
a  few  inches  above  the  wrist,  the  circular  incision  through  the  skill 
would  be  located  one  and  a  half  inches  bolow  the  point  at  which  the 
bones  are  to  be  sawed.  In  the  more  fleshy  portions  of  tho  arm,  nean  r 
the  elboWj^rom  two  to  two  and  a  half  inches  of  skin  would  be  re- 
quired. 

The  circular  flap  being  well  drawn  upwards  by  an  assistant,  the  knife 
is  made  to  encircle  tho  limb  immediately  below  the  fold  of  turncd-up  skin, 
and,  cutting  to  the  bone,  divides  all  of  tho  muscles.  The  point  ol  the 
knife  i.«  then  thru.-t  between  the  radio-  and  ulna  to  divide  the  hit 
on-  ligameni  and  such  muscular  fibres  as  may  have  previously  escaped 
the  knife.  When  ilio  bones  arc  isolated,  a  retractor,  made  by  slitting 
three  tails  in  a  band  eight  inches  wide,  i-  applied  for  the  protection  of 
the  sot'    :  ','■  middle  tail  if   plated  between  tl  'he  lat- 


460  IMPUTATION    OF   THB    FOREARM. 

< nil  and  broadest  tail  "ti  each  aide  of  the  bones,  and  aft  drawn  f 
upwards,  retracting  and  protecting  tb<  soft  parts  f"r  the  formation  of 
the  stamp  (plate  1,  fig.  1).  Tin- saw  is  applied  t «.  t h<-  bonei  Just  be- 
low the  rhtraotor.  In  Its  application,  place  the  heel  of  the  saw  upon 
ill.  nl 1 1 :t  (which  is  the  Immovable  bone  "f  the  forearm),  and  fixing  it 
in  position  between  the  stamp  and  the   thumb  nail   of  the  left  band 

iperator,  he  draw-  the  saw   baokwnrds,  which  at  onoe  makes  a 
proovo  for  itself,  and  pit  ven1  -  the  Instrument  wandering  about  the  limb, 

tiling  the  fingers  of  surgeon  and  assistant.     As  a i  as  ; 

r  itself,    ItS  position  IS  -  I  as  t"  make  it  emn- 

plete  the  section  of  the  radius  (the  rotating,  movable  bone)  before  the. 
sootion  of  the  ulna  is  finished.  Ligate  the  vessels,  usually  two  in  num- 
ber, the  radial  and  ulnar  artery— although,  at  times,  two  others,  the  an- 
terior and  posterior  interosseous,  may  require  ligation.  <  !ul  off  one  end 
of  each  ligature  near  the  Knot,  and  bring  the  other  carefully  from  the 
wound,  securing  all  the  remaining  ends  under  s  piece  o<  adhesive  plaster 

Upon    the  arm:    then    apply  SO  many  points  of   suture   as   will   keep   the 

opposing  edges  of  tl iroular  flap  in  perfect  apposition.     A  wel  olotb 

the  stump  completes  the  dressing. 

Flap  operation  Bg.  •'!.) — Amputating  the  arm  by 

more  flaps  is  an  operation  at  times  preferred,  from  the  rapidity  of  Its 
execution;   or  when,   from   extensive   injur)-  to   the  soft    (■int.-  upon  one 

:    the  frao tared  1 es,  without  wound  on  the  other,  a  single  flap 

made  upon  the  uninjured  side  of  the  arm  would  enable  the  operator  t<> 
amputate  loner  down,  thus  Baving  more  of  the  extremity.  Trans- 
fixion is  the  preferable  mode  of  forming  the  flaps.  The  arm  having 
been  supinated  -  i  that  the  radio-  and  ulna  lie  parallel  to  eaob  other  - 
b   \er;,  itep,  to  av  lid  passing  the  knife  between  the  hones, 

which  would  be  a  most  awkward  acoidonl  for  the  surgeon  who  values 
hi-  reputation     the  operator,  it  operating  upon  the  Left  arm,  Beises  all 

i   parts  in  fronl  of  the  bones  with  hi-  left  hand,  while  h 
the  point    o[   the  knife  through  the  skin  on  the  outer  side  of  the  arm 
down   to  the  outer  edge  of  the   radius,  whioh  itruok   by  Its 

point;  the  handle  of  the  knife  is  then  depressed,  so  as  to  ejpvate  the 

point  and  allow  it  to  glide  upwards  over  the  uppi  redge  of  the  1 ••     A- 

soon  as  the  point  of  the  Knife  escapes  beyond  the  margin  of  the  radius 
its  handle  is  brought  to  the  first  position,  so  as  to  allow  the  blade  of  the 
knife  to  glide  over  t  he  an  tori'  ■  ;  bol  h  radius  and  ulna,  gracing 

When  over  the  ulna,  the  handle  of  the  knife  should  he 
elevated,  whioh  will  depress  the  point;  the  sofl  tissues  over  the  blade 

are  drawn  upwards,  and  the  knife  now  made  to  transfix  the  skin  on  the 
inner  Bide  of  the  arm,    on   a  level  with  the  inner   border  of    the  ulna,  BO 

thai  at  Least  one-half  the  thi  knees  •■>  the  soft  parts  of  the  arm  will  lie 


AMPUTATION    OF    THE    FOREARM.  461 

over  the  blade.  The  knife  is  now  made  to  graze  the  bones  in  its 
descent  for  two  inches,  when  the  nitre  is  turned  directly  upwards  nearly 
at  ri^rht  angles  with  its  former  course,  and,  by  a  §auring  motion,  onts 
it >  way  outwards  through  the  tendons  and  skin.  The  anterior  flap 
being  thus  formed,  the  knife  is  made  to  transfix  the  limb  at  the  point 
where  the  operation  was  commenced  (plate  5,  fig.  .'!).  Passing  now  he- 
hind  the  bones,  the  soft  parts  on  the  back  of  the  arm  being  drawn  back- 
wards, so  that  the  blade  may  readily  transfix  the  arm  without  cutting 
again  the  skin,  the  kuife  is  made  to  graze  the  posterior  surface  of  the 
bones  for  the  space  of  two  inches  in  its  descent,  and  cuts  out  again  at 
right  angles,  with  a  sawing  motion,  to  form  the;  posterior  flap. 

The  two  flaps  are  now  elevated  by  an  assistant,  while  the  surgeon 
passes  the  knife  around  the  limb  on  a  level  with  the  base  of  the  flaps, 
which  enables  him  to  divide  the  remaining  muscular  fibres  directly 
npon  the  bones.  He  also  passes  the  knife  between  the  bones  for  the  pur- 
pose of  dividing  the  interosseous  membrane  and  the  muscles  attached 
to  it.  To  perform  this  step  of  the  operation  successfully,  the  point  of 
the  knife  must  he  thrust  from  below  upwards,  and  the  edge,  in  turn,  he 
brought,  with  a  sawing  motion,  against  both  radius  and  ulna.  When 
withdrawn,  the  point  of  the  kuife  is.  in  a  similar  manner,  inserted  from 

with  the  same  object  in  view.  The  flaps  are  now  well  drawn 
back  by  an  assistant,  who  clasps  the  arm  and  everted  flaps  with  both 
hands  near  the  point  where  the  bones  are  to  be  divided.  If  the  assist- 
ant is  unskilled  the  soft  parts  can  be  well  protected  from  injury  while 
sawing,  by  using  a  retractor  or  piece  of  cloth  fifteen  inches-  long  and 
twelve  inches  wide.  One  end  of  this  is  torn,  half-way  down,  into  three 
strips,  the  central  one  of  which  is  but  one  and  a  half  inches  wide.  This 
Central  strip  is  thrust  between  the  bones,  the  broad  pieces  are  brought 
up  on  either  side  and  drawn  obliquely  over  the  anterior  face  of  the 
Bapi  and  forearm,  which,  when  drawn  firmly  up,  encloses  all  of  the 
soft  parts  in  a  kind  of  bag,  thus  protecting  them  from  being  injured 
by  the 

The  soft  parts  which  are  to  compose  the  stump  being  now  well  pro- 
tected, t! perator  places  the  heel  of  the  saw  upon  the  ulna,  fix> 

;  ion  by  the  nail  of  his  thumb,  which  restri  against  the  side  of  the 
it  from  wandering,  and  drawing  the  saw  backwards 
nearly  the  entire  length  of  the  blade,  makes  ■  groove  for  its  reception. 
When  this  groove  i.-  sufficiently  deepened  by  the  to  and  fro  movements 
of  the  saw,  which  is  permitted  to  cut  chiefly  by  it.-  on  D  weight  and  with 
but  little  pp  .  the  handle  in  so  depn 

,  as,  which,  .1-  :i  movable  bone,  ihould  be 

the  ulna  i  [f  the  arm,  both  above  and  he- 

point  of  amputation,  is  firmly  held,  and  the  saw  allowed  to  mn 

ritfa  hut  little  pressure,  the  bones  will  be  smoothly  cut 


AM1M   DATION    AT   ELBOW-JOINT. 

motions  allowed  la  the  arm.  particularly  if  one  portion  of  the  arm  is 
tilted  upwards,  or  overpressure  made  upon  the  Baw,  will  oanse  the  blade 
to  be  oaught  between  the  bone?,  or  eanae  the  bone--  to  Bnap  before  the 

i  by  the  bbm  has  been  completed,  leaving  an  ugly,  Bbarp  spiou* 
lam  projecting  from  the  extremity  ol  the  bone,  which  must  be  re- 
moved by  the  bone  forceps.  If  this -sharp  point  be  left  it  will  irritate 
the  Baps,  may  cause  ulceration,  and,  protruding  through  the  soft  parts, 
be  the  aouroe  of  long-continued  pain  to  the  Btump.  Two  large  arteries 
will   require  ligation   In  the  anterior   flap — plate  6,  fig.    I     lying   re- 

ely  over  the  radius  and  ulna  bones.  A  third,  and  even  a  fourth) 
mil -h  smaller  vessel,  which  sometimes  requires  tying,  will  be  found  be- 
tween  the  bones  and  upon  either  side  of  the  interosseous  membrane. 
All  the  vessels  are  secured  by  the  assistance  of  a  tenaculum  or  a  bull-dog 
forceps.  This  foroeps  differs  from  the  torsion  or  dissecting  forceps  in 
having  the  ends  shaped  like  the  beak  of  a  sparrow,  and  so  conical  that 
it  is  impossible  for  the  noose  of  the  ligature  to  remain  upon  it.  When 
the  ligature  is  drawn  upon,  it  must  slip  off  the  instrument  uptfn  the  artery 
held  between  its  points.  One  end  of  the  ligatures  is  oul  off  near  the  knol  : 
the  other  is  brought  out  of  one  of  the  angles  of  the  wound,  and  secured 
npon  the  arm  by  a  strip  of  adhesive  plaster.  The  flaps  are  brought  to- 
gether  by  Beveral  points  of  interrupted  suture. 

One  of  the  established  rales  in  surgery  is  always  to  operate  as  far 
from  the  trunk  as  possible)  compatible  with  the  removal  of  all  of  the  dis* 
eased  tissues.  A-  military  surgery  offers  no  exception  to  this  rule, 
cases  frequently  occur  requiring  amputation  in  whiob  the  injury  is  con- 
fined  altogether  to  one  side  of  a  limb.  In  Bucb  cases,  if  the  crushing  of 
;  Des  does  uol  extend  beyond  the  immediate  seat  of  injury,  it  is 

urgery  to  oul  a  long  flap  from  the  uninjured  Bide  of  the  member 
and  amputate  jusl  above  the  fracture,  making  upon  the  injured  Bide  of 
the  limb  a  semioiroular  Lnoision,  joining  the  Hap  a)  righl  angles.  1 1  will 
be  most  convenient  to  make  this  Hap  by  transfixion,  taking  the  precau- 
tion, as  related  above,  of  including  half  the  thickness  of  the  soft  parts 
of  the  limb  in  the  Hap. 


AMPUTATION  AT  BLBOW-JOINT. 

In  diinrlirii/dliii,/  ill   tin   tlbote  joint,  the  anatomy  of  the   osseous  sili- 
Qtering  into  the  Eormation  of  ibis  articulation  must  be  familiarly 

known,  otherwise  great  difficulty  will  be  found  in  getting  between  the 

In  examining  plate  i.  fig's  1 .  -'.  3,  the  forms  of  the  heads  of  the 

radius,  ulna,  and  humerus  oan  be  studied  in  detail,  isolated  as  well 

as  in  juxtaposition,  with  their  lateral  as  well  as  antero-posterior  rcla- 


AMPUTATION    AT    ELBOW-JOINT.  463 

tions.  It  must  be  remembered  that  the  shaft  of  the  humerus,  as  it  be- 
comes developed  to  form  the  head,  not  only  expands  its"*surface,  but  is 
also  surrounded  by  important  prominences  placed  laterally  upon  en- 
largements which  are  called  condyles.  The  outer  elevation,  called  epi- 
condyle, is  the  conspicuous  prominence  visible  on  the  outside  of  the 
elbow,  and  separated  from  the  articulation  of  the  radius  with  the  exter- 
nal condyle  about  half  an  inch — plate  4,  fig.  3.  The  external  lateral 
ligament  which  assists  in  forming  the  elbow-joint,  is  attached  above 
to  this  epicondyle,  below  to  the  head  of  the  radius,  or  rather  to  the  an- 
nular ligament  which  binds  together  the  radius  and  ulna.  The  epitroch- 
loea, a  larger  and  more  prominent  elevation,  situated  upon  the  lateral 
surface  of  the  internal  condyle,  is  in  a  similar  way  related  to  the  ulna, 
giving  attachment  to  the  powerful  internal  lateral  ligament  which 
connects  this  epitrochloea  to  the  inner  face  of  the  head  of  the  ulna, 
and  distant  from  the  articular  face  about  three-quarters  of  an  inch. 

The  articular  face  of  the  humerus  (plate  4,  fig.  1)  presents  two  un- 
equal prominences  ;  upon  the  smaller  or  outer  one  rotates  the  cupped 
head  of  the  radius,  while  upon  the  largor  or  inner  one  tho  head  of  the 
ulna,  with  its  antorior  sharp  coranoid  and  long  posterior  olecranon 
processes,  moves  as  upon  a  pulley.  To  receive  these  prominent  proc- 
esses of  the  head  of  the  ulna  are  two  depressions  upon  the  anterior 
and  posterior  surfaces  of  this  extremity  of  the  humerus,  called  sigmoid 
fossae,  which  permit  the  extended  movements  of  flexion  and  extension  . 
When  the  bones  are  placed  in  their  proper  position  it  will  be  found 
that,  although  the  epicondyle  and  epitrochloea  are  upon  tho  same  plane, 
the  line  of  the  articulation  runs  obliquely  inward  and  downward 
(plate  4,  fig.  3);  the  anterior  line  of  articulation  being  overhung 
by  the  coranoid  process  of  the  ulna  (plate  4,  fig.  2),  while  the  pos- 
terior surface  is  completely  covered  in  by  the  projecting  olecranon  proc- 
ess of  tho  same  bone.  The  main  artery  runs  in  front  of  the  joint. 
In  amputating  by  the  antorior  flap,  which  is  preferred  by  some  to  the 
circular  operation,  the  arm  is  supinated  and  slightly  flexed  (plate  4, 
fig.  4) ;  the  surgeon,  standing  upon  tho  inner  side  of  tho  limb,  and 
u.-ing  a  long  narrow-bladed  knife,  transfixes  the  limb  by  introducing 
the  point  on  the  inner  side  of  the  arm,  one  and  a  half  inchos  below  tho 
epitrochloea  or  prominence  on  tho  inner  condyle  of  tho  humerus.  In 
sage  forwards  the  point  of  the  knife  strikes  tho  side  of  the  ulna. 
Ihe  handle  it  now  depressed  to  allow  the  blade  to  glide  over  the  an- 
terior face  nf  the  bones,  when  the  handle  is  again  elevated  to  allow  the 
point  to  protrude  OK  t  lie  outer  side  of  the  arm,  one  inch  below  the 
epicondyle  "r  prominence  on  the  outer  condyle  of  the  humerus.  A 
made  by  a  sawing  motion  id  the  descent  of  the  knife,  tho  blad  e 
grazing  the  bones  in  Its  downward  movements,  until  four  inches  is  trav- 
ersed, when  it  is  turnod  directly  outward?  and  the  flap  completed.     In 


\>\\  AMPUTATION    AT    BLTKW-JOTNT, 

ling  ilic  arm  for  this  flap,  unless  the  bonca  arc  kept  parallel  by 
placing  ili>'  ffircarm  in  supination,  the  point  of  the  knife  may  1 
tween  the  bone*— ft  very  awkward  accident. 

tlii-  flap,  he  at  the  same  time  compresses  the  main  arteries  which  trav- 
erse it,  controlling  the  hemorrhage,  [f  the  -Kin  bo  properly  r<  tracted  by 
an  assistant,  the  points  at  which  the  knife  transfixed  the  arm  will  havo 
beon  drawn  up,  corresponding  closely  to  the  articulating  surfaoea 
(plate  .r>,  fig.  5),  viz:  half  an  inch  below  tin-  epicondyle  and  threes 
quarters  of  an  inch  below  the  epitroohloea.  The  round  head  of  the 
radius  being  dearly  distinguished,  the  operator,  stooping,  with  his 
hand  under  the  arm  t"  be  removed,  places  the  heel  of  the  knife  at  the 
outer  angle  of  the  incision,  and  with  a  sawing  motion  makes  a  semi- 
circular cut  around  the  back  of  the  arm,  terminating  at  the  point! 
of  transfixion.  In  dividing  tho  skin  at  this  step  of  the  operation,  if 
the  surgeon  has  marked  well  the  osseous  prominences,  tin;  blade  of 
tho  knife  should  be  made  to  glide  betweon  tho  head  of  the  radius 
and  the  condyle  of  the  humerus.  The  articulation  of  the  ulna  with 
humerus  is  now  attacked  from  in  front,  by  the  division  of  the  re- 
maining muscular  fibres  tot  .-.  rered  in  making  the  flap,  and  also  by 
the  division  of  the  internal  and  anterior  ligaments,  which  arc  put 
upon  the  stretch  by  extending  foroibly  the  forearm.  Should  there 
be  any  difficulty  in  finding  the  situation  of  these  ligaments,  it  is  only 
necessary  to  refer  to  the  epitrochlcea;  three-quarters  of  an  inch  be- 
low it  the  articulation  will  always  be  found.  The  articulation  hav- 
ing beon  largely  opened  in  front,  continued  forced  extension  will 
luxate  the  olecranon  process  from  its  deep  sigmoid  fossa,  when  tho 
triceps  muscle  attached  to  this  prominence  should  he  out  oil'  close  to 
tho  bone,  ami  the  forearm  removed  in  the  line  of  inoision  already 
i  on  the  back  of  the  arm.  The  radial  and  ulna  arteries  and,  per- 
baps,  also  tie-  interosseous,  will  require  ligation,  'flu-  ligatui 
brought  out  at  one  of  the  angles  of  the  wound,  and  the  (lap  secured  in 
its  position  by  several  points  of  suture.  A  single  thickness  of  wet 
oloth  over  the  stump  completes  the  dressing. 

The  circular  amputation  at  the  elbow-joint  is  an  operation  which 
gives  equally  good  results  with  that  of  the  anterior  (lap.  Tho  ar.n  is 
held  in  supination  and  slightly  flexed,  and  the  brachial  or  axillary 
artery  secured  by  pressure  with  the  fingers,  either  in  the  axillary  space 
at   the  junction  of   the  anterior   with    the  mi. Idle  third  of   this  space,   in 

which  line  the  axillary  artery  can  always  he  found  running  directly 
over  tho  head  of  tho  humerus,  and  at  which  point,  owing  to  its  super- 
ficial seat  being  covered  only  by  skin  and  cellular  tissue,  and  lying 
upon  hone,  tho  circulation  through  it  can  be  most  readily  controlled] 
or,  as  tho  vessel  courses  through  the  arm  on  the  inner  side  of  the  biceps 


AMPUTATION    OF   THE    ARiM.  165 

muscle,  where  it  is  readily  felt,  surrounded  by  its  reins  and  accompa- 
nying nerves.  If  an  intelligent  assistant  is  at  hand,  the  artery  can  bo 
readily  secured  in  cither  position.  Should  it  be  necessary,  however,  to 
use  the  tourniquet,  this  can  only  be  "applied  upon  the  arm  about  its 
middle  and  over  the  inner  border  of  the  biceps  muscle.  The  test  of 
the  proper  application  of  the  tourniquet  will  be  the  complete  control  of 
the  circulation,  with  cessation  of  the  pulse  at  the  wrist.  As  the  tour- 
niquet in  general  use  clasps  the  entire  limb  so  tightly  as  to  stop  both 
arterial  aud  venous  circulation,  deep-seated  as  well  as  superficial, 
much  blood  is  usually  removed  in  the  limb.  The  fingers  of  a  good 
assistant,  which  is  in  every  case  to  be  preferred,  will  only  compress 
the  limb  at  two  points  :  one  over  the  seat  of  the  vessel,  and  a  point  of 
counter-pressure  upon  the  opposite  side  of  the  limb.  As  this  methodi- 
cal pressure  does  not  embarrass  to  any  great  extent  the  venous  circu- 
lation, the  blood,  which  otherwise  would  be  incarcerated  in  the  con- 
demned member,  has  an  opportunity  to  escape,  and  the  imputation  will 
be  effected  with  very  little  loss. 

The  circular  operation  is  commenced  by  the  surgeon  in  a  kneeling 
posture,  passing  the  knife  under  the  arm,  so  as  to  make  an  incision  on 
the  outer  and  upper  part  of  'the  arm,  three  fingers'  breadth  from  the 
fold  of  the  elbow.  I?y  a  sawing  motion  a  circular  line  is  traced  on 
the  outer,  under,  and  inner  side  of  the  arm,  the  operator  rising  from 
the  kneeling  posture,  which  enables  him  to  watch  the  heel  of  the 
blade,  and  direct  properly  the  line  of  incision.  As  it  would  strain  the 
wrist  to  perfect  the  incision  on  the  upper  surface  of  the  arm,  it  Is  pref- 
erable, although  not  so  brilliant  a  step  in  the  process,  to  change  now 
the  position  of  the  knife,  and,  placing  the  blade  over  the  arm  in  the 
incision  where  first  commenced,  complete  it  by  cutting  toward  the 
operator,  thus  joining  the  two  terminations  of  the  first  incision. 

Although  this  incision  should  extend  solely  through  the  skin  and 
cellular  tissue,  however  sharp  the  Made  may  be,  unless  the  operati  i  ap- 
plies a  sawing  motion  to  the  knife  the  skin  will  be  very  irregularly 
divi  ded,  and  at  points  not  cut  at  all.  As  the  vessels  are  deeply  seated, 
an d  the  skin  alone  i.-  required  to  form  i be  flap,  the  incision  should  he  only 
skin -dee) i,  so  u  to  avoid  the  loss  of  blood  during  the  tedious  pn 
dissecting  up  the  circular  flap.  When  the  circular  incision  hi 
completed  the  operator  Beizee  the  upper  <  dge  of  the  incision  with  a  for- 
ceps, and  by  trokei  of  the  knife — using  a  scalpel,  if  he  pre- 
fers it  to  the  amputating  Unite — di  llular  bands  uniting  the 
skin  to  the  d(  -.  When  the  ,-i.in  baa  been  sufficiently  under- 
i  and  rapidly  dissected  upwards  until  sufficient 
skin  is  obtained  to  cover  the  head  of  tie  humerus,  which  « ill  bring  the 

fl;ip  on  a  hvel  with  the  articulation.  By  a  bold  Sweep  of  the  knife 
(plate  4,  fig.  6)  all  the  muscles  are  divided,  the  blade  panting  1 


46G  AMPUTATION    01   THE    ABM. 

i  of  the  humerus  and  radius,  the  artioulation  opened  from  t lie 
front   and  the  oper.-ition  oomplel  •  1  by  is  ilating  the  ole  iran  in. 


AMPUTATION  OP  THE  ARM. 

In  amputating  the  arm  in  either  its  upper,  middle,  or  lower  third, 

any  one  of  the  various  described   methods  may  be  used  with  equally 

suits.     It  would  be  useless  here  to  describe  again  the  circular 

operation,  or  dissecting  up  of  a  circular  flap  of  skin    with   which  to 

form  a  stump,  as  this  operation  upon  the  arm  would  differ  in  no  res] t, 

except  in  situation,  from  that  performed  upon  the  forearm,  aud  which 
has  been  already  so  minutely  detailed.  The  circular  amputation, 
upon  whatever  portion  of  a  limb  performed,  presents  a  striking  uni- 
formity in  its  procedure.  The  skin  should  always  be  divided  suffi- 
ciently below  the  point  where  it  is  designed  to  saw  the  hones,  so  as  to 
allow  an  ample  covering  of  soft  tissues  for  the  extremity.  A  good 
rule  would  be  to  make  the  distance  bet  w. ten  the  incision  in  the  skin  and 
the  point  of  division  in  the  bone,  or  removal  at  the  joint,  equivalent  to 
half  the  diameter  of  the  Limb,  allowing,  in  addition,  from  one-half  to  one 
Inch  for  retraction  of  the  -kin  :  e.  /.,  if  an  arm  is  four  inches  in  diame- 
ter, the  incision  through  the  skin  should  be  from  two  and  a  half  to 
three  inches  below  the  point  where  the  bone  will  be  divided.  Aooord- 
this  rule,  if  a  thigh  is  six  inches  in  diameter  the  skin  will  be 
divided  four  inches  below  the  point  of  amputation.  By  following  this 
rule  a  Buffioienoy  of  skin  will  be  had  for  covering  the  stump,  permitting 
ready  adjustment  without  traction  upon  the  sutures  used  in  closing  the 
wound. 

A  modification  of  the  circular  operation,  well  adapted  to  the  arm  or 
thigh,  where  a  single  bone  is  surrounded  on  all  Bides  by  muscular  en- 
velopes, has  for  its  object  the  formation  of  a  muscular  cushion  for  the 
Immediate  covering  of  the  sawed  surface  of  the  bone,  and  is  thought 
by  many  operators  I"  form  u  more  symmetrical  stump  than  where  the 
bone  is  covered  solely  by  skin.  Heforo  chloroform  was  used,  an  addi- 
tional reoommendation  was  rapidity  in  its  performance;  but  as  a  nur- 
geoo  should  never  operate  against  time,  a  few  second-  more  or  loss  in 
completing  an  amputation,  under  chloroform,  la  an  item  not  worthy  of 

( Bideration.     The  arm  being  drawn  ouf  al   right  angles  to  the  body, 

.■in  assistant   compresses  fl"'  axillary  artery  as  it  ooursos  over  the  head 
of  the  humeral,  and  another  olaspc  the  arm  above  the  point  where  the 
incision  is  to  be  made,  at  the  same  time  retracting  evenly  the  skin.    The 
surgeon,  placed  upon  the  inner  si  le  of  the  arm  if  he  is  operatic 
the  right  arm,  or  on  the  du(i  (  lids  it   the  left,  stooping  or  kneeling,  ns 


AMPUTATION    OF    THE    ARM.  467 

most  convenient,  with  his  arm  passed  under  the  arm  to  be  removed, 
places  the  heel  of  the  knife  on  the  upper  surface  of  the  arm,  its  point 
reaching  over  his  shoulder,  and  with  a  rapid  sawing  motion  sweeps 
around  the  arm,  completing  a  circular  incision  which  extends  through 
the  entire  thickness  of  skin. 

The  watchful  assistant  at  once  retracts  evenly  the  skin  to  the  extent 
of  nearly  an  inch,  ami  the  surgeon,  placing  the  heel  of  the  knife  in  the 
position  where  he  commenced  the  operation  on  the  upper  surface  of  the 
arm  and  at  the  edge  of  the  retracted  skin,  makes  a  second  Circular 
swe'ep  over  the  Hmb,  passing  now  through  all  of  the  tissues  down  to 
the  bone.  The  assistant,  placing  his  fingers  deeper  into  the  wound,  re- 
tracts to  B  much  greater  extent  the  skin,  with  superficial  muscles,  when 
the  surgeon  places,  for  the  third  time,  the  heel  of  the  knife  on  the  upper 
side  of  the  arm,  upon  the  level  of  the  retracted  edge  of  the  skin  (plate 
5,  fig.  5),  and  incises  again  the  muscles  directly  to  the  bone,  dividing 
carefully  all  the  muscular  fibres.  A  retractor,  or  piece  of  cloth  twelve 
inches  wide,  slit  from  one*  end  half-way  down,  so  as  to  make  a  double- 
tail  bandage,  is  passed  around  the'bone,  the  soft  parts  retracted  by  it, 
so  as  to  avoid  any  laceration  of  these  muscles  with  the  saw,  and  the 
bone  sawed  off  as  near  the  retractod  soft  parts  as  possible. 

Plate  5,  tig.  6.  shows  the  relation  which  the  end  of  the  bone  bears 
to  the  soft  envelopes  forming  the  stump,  and  shows  how  well  and  per- 
fectly it  is  embedded  in  the  muscular  layer,  and  how  completely  the 
flap  of  skin  is  protected  from  the  sharp  edges  of  the  bono.  In  the  am- 
putation of  the  arm  the  brachial  artery  is  the  only  large  vessel  requir- 
ing a  ligature,  and  is  found  always  on  the  inner  side  of  the  humerus, 
lying  obliquely  inward  and  upward. 

In  amputating  the  arm  by  the  double  flap,  the  surgeon  reverses  his 
position,  so  that  lie  can  seize  with  his  left  hand  the  tissues  from  which 
he  designs  cutting  the  flap,  and,  by  drawing  upward  the  soft  pi 
the  arm,  he  can  so  transfix  the  limb  with  the  knife  as  to  have  fully 
one-half  the  thickness  of  the  limb  in  the  first  flap.  The  limb  U  BO 
transfixed  as  to  form  an  outer  flap,  and  thus  avoid  the  humeral  artery, 
the  division  of  which  should  be  left  for  the  second  or  inner  flap.  The 
left  hanl  of  the  operator  retains  its  position,  holding  upward  the 
part  of  the  arm,  until  he  baa  made  an  incision  parallel  with  the  arm.  as 
long  as  half  the  diameter  of  the  limb,  when  he  cuts  directly  outward^ 
lib-rating  the  flap.  He  now,  with  his  left  hand,  draws  tin?  remaining 
tissues  downward,  so  that  the  knifejnay  readily  pass  uuder  the  bone* 
through  the  I  the  point   where  the  awn  was  first   tran 

without  notching  or  in   nny  way  involving  a  second   time  the  -kin.      An 
la  made,  in    the  descent  of  the  knife,  of  similar  length  to  thai 
on  the  npper  side  of  the  bone,  when  t  he  edge  of  the  knife  la  turned  out- 
ward, and  the  skin  divided  to  complete  the  lower  or  Inner  flap. 


468  AMPUTATION    AT   SHOTJLDEIt-JOINT. 

flaps  are  now  drawn  backward  by  an  assistant;  the  surgeon  sweeps  the 
knife  around  the  bone  at  th<'  base  of  the  Haps,  so  as  to  divide  all  the 
remaining  muscular  fibres  which  had  not  beeu  included  in  the  former 
incisions.  While  the  Hups  are  now  carefully  drawn  backward,  being 
clasped  by  both  the  hands  of  an  assistant,  >>r  a  retractor  with  two  tails 
nsed  for  the  protection  of  the  flaps,  the  surgeon  divides  the  hone  with 
the  saw.  having  fixed  the  blade  upon  the  humerus  by  supporting  it 
with  the  nail  of  his  thumb.  When  the  limb  has  been  removed,  any 
gpicula  of  bone  left  protruding  from  the  humerus  must  be  nipped  off 
with  the  bone  pliers.  The  brachial  artery  is  drawn^uit  by  the  tenacu- 
lum or  forceps,  isolated  from  its  accompanying  veins  and  nervi 
tied  with  a  well-waxed  thread,  before  the  assistant  relaxes  pressure 
upon  the  axillary  vessel.  Any  vosscls  which  throw  a  jet  of  blood,  how- 
ever small,  should  be  ligated,  one  end  of  the  ligature  cut  off,  and  t he 
other  brought  out  of  one  of  the  angles  of  the  wound,  and  secured 
from  injury  two  inches  above  the  incision,  under  a  piece  of  adhesive 
plaster.  The  wound  is  closed, -as  in  all  stftnips.  by  several  points  of 
suture,  which  should  include  the  entire  thickness  of  skin,  but  not  the 
muscles.  Plate  5,  fig.  7,  shows  the  formation  of  the  outer  and  inner 
11  ap s,  with  the  relative  position  of  the  bone,  forming  the  apex  of  a  tri- 
angle. 


AMPUTATION  AT  THE  SHOULDER-JOINT. 

In  cases  where  the  humerus  has  been  shattered  within  two  in 
the  glenoid  cavity,  without  involving  the  head  of  the  hone  in  the  injury, 
or  in  any  way  implicating  the  joint,  Burgeons  prefer  amputating  the  limn 
without  retno\  ing  the  head  of  the  bone.    By  sawing  through  the  humerus 
just  above  Its  fraotured  Beat,  the  amputation  is  simplified,  both  as  to  the 

operation  and  its  results,  while  the  rotundity  and  symmetry  of  the  shoul- 
der is  retained.  W.  however,  the  injury  to  the  bone  extends  into  the  joint, 
while  al  the  same  time  the  soft  parts  are  so  lacerated  as  to  preclude  the 
possibility  of  reseoting  the  head  of  the  humerus, then  disarticulation  must 
be  resorted  to,  in  order  to  save  life  at  the  expense  of  the  limb.  The  shoul- 
der-joint is  formed  by  the  scapula  and  humerus,  and  protected  above  hy 
the  clavicle.  Plate  6,  Bg.  1,  indicates  how  the  round  head  of  the  hume- 
rus is  reoeived  lato  th«  flat,  Baucer-sbaped  head  of  the  Bcapula,  in  con- 
tact with  which  it  is  retained  more  by  the  scapula  muscle,  attached  to  the 
greater  and  le.-.-cr  tuberosities  of  the  humerus,  than  by  the  capsular  liga- 
ment. The  B/Coromial  process  of  the  scapula,  with  claviole  attached 
(plate  5,  Bg.  2).  protects  the  articulation  from  above,  while  the  coranoid 
process,  jutting  from  the  base  of  the  glenoid  cavity,  protects  the  joint 
from  within. 


AMPUTATION    AT    SHOULDER-JOINT.  469 

Two  methods  arc  equally  applicable  for  this  disarticulation  !  a  double 
flap  operation,  generally  known  as  Lisfrane's,  and  the  oval  mothod,  or 
Larrey's  process. 

Lisfrane's,  or  the  lateral  flap  amputation  at  the  shoulder-joint, — Tbc 

patient  having  been  chloroformed  and  brought  to  the  edge  of  the  bed, 
the  surgeon,  having  located  with  care  the  space  between  the  coranoid 
and  accromial  processes,  seizes  the  arm  firmly  in  his  left  hand,  and  car- 
rying it  upward  and  outward,  if  it  bo  tho  left  arm  requiring' removal, 
passes  the  point  of  a  long,  narrow,  sharp  knife  (plate  6,  fig.  3)  into  the 
middle  of  the  posterior  fold  of  the  axilla,  and  pressing  it  obliquely  up- 
ward, makes  it  strike  fairly  the  head  of  the  humerus.  By  depress- 
ing the  handle  of  the  knife,  the  point  of  the  blade  is  made  to  glide  over 
the  head  of  the  humerus,  cutting  through  the  capsulo,  and  continuing 
onward,  between  the  head  and  the  accromial  process,  perforates  the 
akin  upon  the  anterior  portion  of  the  arm,  through  the^paoc  bounded  by 
the  clavicle  with  coranoid  and  accromial  processes  of  the  scapula. 
Should  it  be  the  right  arm  requiring  removal,  this  step  of  the  operation 
is  reversed — the  knife  entering  in  this  triangular  space,  and  after  pass- 
ing through  the  capsule  and  over  the  anterior  face  of  the  head  of  the 
bone,  appears  through  the  posterior  fold  of  the  axilla.  Tho  deltoid 
muscle  being  still  relaxed,  the  point  of  the  knife  descends  in  the  line, 
a  b,  until  the  blade  is  brought  to  a  horizontal  position,  when  it  com- 
pletes an  outer  flap  from  four  to  five  inches  long,  in  the  line  of  incision 
a  L  c.  This  Hup  is  at  once  drawn  up  by  the  assistant  ;  and  as  there 
are  no  important  vessels  in   it,  but  little  bleeding  occurs. 

The  position  of  the  arm  is  now  changed,  as  it  is  brought  down  and 
carried  forcibly  across  the  chest,  which  throws  the  head  of  the  hu- 
merus backward  and  upward,  making  tense  the  capsular  ligament,  and 
shows  the  opening  made  into  the  joint  by  tho  passage  of  the  knife.  Tho 
point  of  the  knife  is  now  drawn  firmly  across  the  capsule,  and  as  the 
arm  is  rotated  forcibly  inwards  and  then  outwards,  all  of  the  muscles 
attached  to  the  greater  and  lo.-ser  tuberosity  of  the  humerus  are,  in  turn, 
divided  by  this  incision,  which  opens  the  joint  largely,  and  allows  the 
I  tin-  humerus  to  .-lip  out  from  its  covering.  The  blade  of  the 
knifeis  then  passed  on  the  inner  side  of  the  head  of  the  bone,  completes 
the  section  of  the  capsular  ligament  where  it  is  attached  to  the  neck  of 
the  humerus,  and  grazing  the  bone  for  tho  distance  of  three  inehes, 
allow-  ample  room  for  the  assistant  to  follow  the  knife  with  the  thumb 
of  bis  right  band  buried  in  the  wound,  ami  to  seize  the  pulsating  brach- 
ial artery  between  the  thumb  within  the  wound  and  the  fingers  of  the 
right  hand  in  the  axillary  space.  As  BOOS  a-  the  artery  is  firmly  se- 
cured in  the  fingers  of  the  assistant,  tin-  operator  completes  the  ■ 
of  the  inn-r  flap  '  iv  outward  to  the  Burface  (plate  5, 


170  AMPUTATION    AT    BIIOULDER-JOINI 

forming  a  flap  of  similar  length  ; 
tho  arm.     The  objeot   in  grrwir.p  the-  humerus  in  i lie  descent  of  the 

knife  is  to  avoid  catting  any  vessel,  and  < >i [ally  the  axillary  artew, 

until  it  could  lie  secured  in  the  Bap  by  an  assistant,  If  thi.-  step  of  the 
operation  la  properly  performed,  there  is  no  necessity  in  attempting  to 
compress  the  Bubol avian  artery  above  the  claviole,  which  i.-  ti ■  •  t  only  a 
difficult  manoeuvre,  owing  to  the  positions  into  which  the  arm  most  be 
placed,  bat  cramps  thi  operator.  When  the  am]iutati<in  is  completed] 
the  large  brachial  artery  it  carefully  seoared  by  ligature  before  the 
assistant  loosens  bis  hold  upon  the  vessel.     The  ciroumfh  i 

[aire  tying-  If  the  amputation  be  porformed  for  disease,  the 
glenoid  cavity  must  be  oarefully  examined,  ami  any  necrosed  portion 
be  removed  l>y  the  pliers  or  gouge  :  several  points  of  suture  close  tho 
wound,  the  ligatoi  al  at  the  superior  portion  of  the  wound. 

A  small  opening  is  allowed  at  the  inferior  portion  of  the  flaps  for  drain- 
ago  from  the  cavity  of  the  stamp. 

Lam  if'*  operation,  or  the  oval  method. — The  steps  of  this  operation 
follows:  The  limb  being  placed  parallel  with  the  trunk,  the 
g  the  arm  by  passing  his  Dngera  In  the  axilla  and 
thumli  on  the  outer  side.  -..  as  t"  force  outward  the  head  of  the  hum  cms 
(plate  6,  Bg.  5),  throats  thi  point  of  a  Btrong,  stout  knife  into  the 
shoulder,  immediately  below  the  aocromial  process,  and  makes  a  longi- 
tudinal incision  of  two  inches  in  length,  extending  down  to  the  bone. 
From  the  extremity  of  this  be  makes  an  incision  on  each  side  of  the 
joint,  passing  obliquely  downward  and  outward,  forming  an  open  V« 

rectly  tO  the  bone,  and  tWO  flaps  are  disserted  boldly 
up.  BO  ^  t..  .  xpi  -'  the  articulation.  Wit  bthe  point  "I  the  knife  care- 
fully guided  by  the  surgeon,  so  that   it  can  not  wander  al t  In  the 

depth  of  the  incision  to  woand  Important  vessels,  the  anterior  portion 
of  the  capsule  is  Largely  opened,  the  muscles  attached  I 

ter  t  ni iitj  divided,  and  the  head  of  tbe  humerus  fori  ed  out, 

by    using  the  arm  as  s  lever,  or  i>\   tbe  fingers  in  the  armpit     The 
blade   ol  the   knife   is   then   passed   behind   the  humerus,  grating  the 
bone   downward  for  nearly   three   inohes.     Tho   assistant  follows   the 
knife  in  thewonnd  to  secure  tbe  humeral  artery  between  his  flngt 
prevent    bleeding,  when  the  Hap  is  cut  directly  outward   toward   the 

axilla,  ipleting  such  a  dap  as  Is  seen  In  plate   6,  fig.  6.     During 

this  amputation  the  olrcumfli  in   divided  in  the  fust  step  of 

ration,  and  arc  seonred  by  the  fing<  r  ol  an  a -si -taut  compressing 

in  th<'  wound.      Is  the  brachial  artery  is  in  the  inferior  portion  of  the 

flap,  it  c.in  be  readily  Beoured  by  an  assistant  before  dn  ided.    All  bleed- 

are  tied,  and  the  opposing  surfaces  of  the  flap  retained  in 

by  a  sufficient  nambi  r    I  sutures, 


AMPUTATION    OF   TOES.  471 

The  disarticulation  of  the  shoulder  can  he  equally  effected  by  an 
anterior  and  posterior  flap,  or  by  a  single  long  anterior  Hap  formed  of 
"the  dcltojjj  muscle — Dupuytren's  method. 


AMPUTATIONS  UPON  THE  INFERIOR  EXTREMITY. 

In  amputation  of  a  toe  (plate  7,  fig.  8),  either  by  the  double  lateral 
flap  or  the  oval  method,  identically  similar  steps  arc  followed  as  for 
the  amputation  of  a  finger,  and,  therefore,  the  minute  detail  of  this 
operation  need  not  to  be  repeated.  The  same  rule  holds  good  for  am- 
putation 6T  alhVthe  toes,  as  seen  in  plate  7,  fig.  5.  A  double  flap  is 
made,  with  convexity  downward,  including  all  of  the  soft  parts  extend- 
ing to  the  intcrdipit.il  web,  both  upon  the  back  of  the  foot  and  from 
the  sole.  It  requires  all  of  these  soft  parts  to  cover  the  heads  of  the 
metatarsal  bones  without  making  traction  on  the  flaps. 

The  tarso -metatarsal  amputation,  or  Lisfrane's,  is  an  operation  per- 
formed much  more  frequently  than  required.  The  articulation  between 
the  tarsal  and  metatarsal  bones  is  an  intricate  one,  requiring  much  an- 
att  mical  knowledge  to  open  with  facility  the  line  of  joint,  while  a  saw 
run  through  the  metatarsal  bones,  an  inch  more  or  less  from  the  joint, 
would  simplify  wonderfully  this  troublesome  operation.  In  gunshot 
injuries  to  the  anterior  portion  of  the  foot,  in  advance  of  the  tarsal 
bones,  where  amputation  is  necessary,  the  transverse  section  of  the 
tarsal  bones  is  one  always  to  be  preferred,  and  should  be  the  method 
regularly  adopted  in  army  surgery.  'When,  as  the  result  of  diseased 
action  from  gunshot  injuries,  the  heads  of  the  metatarsal  bones  be- 
coTiie  involved,  Lisfrane's  amputation  may  become  necessary.  In  all 
amputations  through  the  foot,  whether  it  be  by  section  of  bonos  or 
isolation  at  joints,  the  flap  to  cover  the  end  of  the  stump  is  formed 
from  the  sole  of  the  foot. 

If  we  examine  plate  7,  fig.  1,  we  wilj  see  that  four  irregular  bones, 
01  mprisiog  the  anterior  row  of. the  tarsus,  arc  opposed  to  the  heads  of 
the  metatarsal  bones  of  the  five  toei  -  all  of  these  bones  being  intimate- 
ly bound  together  by  ligaments.  If  the  index  finger  of  the  operator 
runs  over  the  inner  face  of  the  big  toe.  and  continues  upward  upon 
the  inner  side  of  the  foot,  after  passing  over  the  shaft  of  the  metatar- 
sal   bone  "t"  the  big  toe  it  meeti   with  a  prominence,  then  n  slight  de- 

ii.    and    immediately    a   second   elevation.     The  first   of  tl 
the   prominent   head  of  the  metatarsal   bone,  the  second  an  eli 
upon  the  inner  face  of  the  internal  cuneiform,  <j.  and  the  depression  be- 
tween  them   marks  the  articulation.      In   passing  the  finger  over   the 
outer  side  of  the  little  toe  at   junction  with  metatarsal  bone,  a  decide'! 


472  TARfi  \MITTAT! 

prominence  is  felt  a  little  beyond  the  middle  of  the  f<">t.  which  i 
ponds  with  the  projecting  head  of  the  fifth  metatarsal  bone,/.     Imme- 
diately behiflid   it    is   ita   articulating   surface  with    the  cuhafd 
Should  utiy  diffioaltj  exist  in  determining  the  articaiation  of  the  big 
thia  head  of  the  little  toe  i-  always  very  prominent,  one  inch  in 
front  of  n  line  drawn  from  tlii-  prominenoe  directly  act 
will  correapond  with  the  articulation  of  the  tir-t  metatarsal  and  inter- 
nal cuneiform. 

ring  been  determined,  the  fool  to  be  removed  ii 
drawn  down  until  the  heel  rests  npon  the  edgi  or  resisting 

The  palm  oi  the  left  hand  of  the  operator  ia  applied  t.«  the 
able  of  the  foot,  the  thumb  marking  the  head  of  the  metatarsal  < 
the  little  toe,  if  it  be  the  right    fool   to  be  amputated, ami  the  index 
plate  7.  fig.   l)  marking  the  site  of  the  corresponding  artionla 
Hon  of  the  external  cuneiform   with  the  first  metatarsal.     Tl  • 
npon  the  dorsum  "f  the  foot  having  been  drawn  backward  by  an  aa- 
inoiaion  is  made  a  little  below,  but  terminating  at 
the  points  indicated  by  the  thumb  and  index  linger.-.     Saving  i  i 
well  the  bones  by  dividing  all  the  tendons  passing  over  the  baok  "i 
the  foot,  the  point  of  the  knife  is  paaaed  around   the  promint 
the  head  <>f  tin-  tilth   metatarsal   bone,  when   it   at  once  enters   the 
joint  between  this  bone  and  the  ouboid,  and,  following  a  slightly  oun  ad 

line  downward  and  inward,  pauses  between  the  fourth  and  third  meta- 
tarsal -n  one  .-id''  (plate  7.  Ii--  ■  'he  cuboid  and  external 
cuneiform,  /  i,  on  the  niher.  Its  further  progress  is  now  haired  by 
sond  metacarpal  hone,  2.  which,  passing  further  hack- 
ward  than  anj  other  of  the  five  hones,  is  received  in  a  box  formed  be- 
tween 'he  internal  and  externa]  cuneiform  bones,  t  g.  It  is  here  inti- 
mately seemed  in  place  by  strong  Interosseous  ligaments,  whioh  can 
only  be  severed  by  adopting  the  course  exhibited  In  plate  7. 
The  heel  of  the  foot. being  firmly  kept  upon  the  e  I  ible  by 
listant,  the  surgeon,  drawing  the  portion  of  the  foot  to  be  re- 
moved firmly  downward,  thrusts  the  point  of  the  knife  very  obliquely 
hetwi  ■  d  the  upper  portion  of  the  Intermuscular  Bpaoe  between  the  first 

metatarsal  b s,  until  he  feels  that  the  point  has 

beyond  the  depth  of  the  artloulation,  when,  by  raising  the  handle  of 
the  knife,  the  end  of  the  blade  divides  the  Interosseous  ligaments,  as 
seen  >"  the  figure,     a  similar  procedure  is  effected  between  the  heads 

Of  the    s,e. ,nd    and     third    metatarsal     hone    to    divide     the     ligaments 

uniting  the  head  of  the  seoon  i  metatarsal  bones  with  the  middle  and 

external  OUnelform.  If  the  anterior  portion  of  the  loot  he  now  drawn 
forcibly  downward,  ami  the  point  of  the  knife  he  drawn  over  the  back  of 
the  foot  aorOSS  the  suppO  'he  articulation,  between  the  second 

metatarsal  .md  middle  cuneiform,  2,  •.  it  will  op^n.  and  also  cause 


chopart's  amputation  of  the  foot.         473 

the  ligaments  binding  the  head  of  the  first  metatarsal  to  the  internal 
cuneiform  to  yield,  when  the  section  of  all  the  anterior  ligaments  will 
be  completed,  and  the  joints  widely  opened,  as  in  plate  7,  fig.  7.  As 
soon  as  the  blade  passes  into  the  sole  beyond  the  articulating  faces  of 
the  bones  the  blade  is  placed  horizontally,  the  toes  elevated,  and  a  flap 
is  cut  parallel  with  and  grazing  the  inferior  face  of  the  metatarsal 
bones.  When  the  knife  has  traversed  nearly  the  entire  length  of  th'o 
of  the  foot,  the  toes  are  again  depressed,  the  portion  of  the  foot  to 
be  removed  held  perpendicularly  to  the  flap,  and  the  knife,  also  held 
perpendicularly,  carves  out  a  regular  termination  for  the.  flap,  and 
separates  it  from  the  foot,  as  in  plate  7,  fig.  8.  It  requires  the  entire 
length  of  tho  sole  of  the  foot  to  form  a  flap  sufficiently  long  to  cover 
readily',  without  traction,  the  exposed  surfaces  of  the  tarsus — plate  8, 
fig.  1,  a  a  a.  The  sesamoid  bones,  at  the  ball  of  the  big  toe,  will  inter- 
fere with  the  formation  of  the  flap  if  their  presence  is  not  recognized  and 
the  knife  made  to  glide  over  them.  Ligation  of  the  plantar  and  dorsal 
arteries,  and  closing  the  wound  by  attaching  the  flap  to  the  anterior 
incision  upon  the  dorsum  by  means  of  a  sufficient  number  of  sutures, 
completes  the  amputation. 

Chopart's  amputation,  or  the  medio-tarsal,  between  tho  scaphoid  and 
cuboid  in  front  (plate  7,  fig.  1,  e  f)  and  the  astragalus  and  os  calcis 
behind,  c  d,  is  performed  in  a  similar  manner  to  Lisfrano's,  the  flap 
being  taken  altogether  from  the  sole — plate  8,  fig.  I,  b  b  b.  The  me- 
dio-tarsal joint  is  found  by  the  following  laudmarks:  In  examining 
plate  7,  fig.  1,  the  outer  surface  of  the  scaphoid  bone  forms  quite  a 
prominence,  which  can  readily  be  felt  by  running  the  index  finger 
upward  upon  the  inner  face  of  the  foot.  The  first  projection  felt  is 
the  head  of  the  metatarsal  bone  of  the  big  toe,  1;  then  the  promi- 
nence of  the  internal  cuneiform,  g ;  and  the  third  knob  felt  as  tho 
finger  passes  toward  the  heel  on  a  line  with  the  extremity  of  the  inner 
malleolus,  is  upon  the  scaphoid  bone,  e.  Immediately  behind  this 
third  knob  is  the  articulation  between  the  scaphoid  and  astragalus. 
aid  the  foot  be  examined  from  behind,  three-quarters  of  an  inch 
in  front  of  the  inner  malleolus  will  bo  found  the  prominence  upon  the 
scaphoid  bone,  behind  which  is  the  articulation.  On  the  outside  of  the 
foot  the  articulation  of  the  cuboid  with  the  anterior  face  of  the  08 
calcis  is  found  with  equal  facility.  The  prominent  head  of  tho  meta- 
tarsal bone  oT  tho  little  too  can  always  be  felt;  one  inch  behind  this  is 
the  articulating  surface:  or  immediately  in  front  of  the  external  mal- 
leolus is  a  tubcrHc  upon  the  outer  face  of  tho  os  calcis,  and  fa  front 
of  this  is  the  joint. 

In  operating  upon  the  left  foot,  it  i^  seised  in  the  left  palm  of  the 
surgeon,  with   the   prominent  landmarks  for  the  joint   marked  by  the 

* 


•  17  1  BYME'e    AMPUTATION    OF   THE    FOOT. 

thumb  upon  t he  tubercle  of  the  scaphoid  and  index  finger  of  the  loft 
hand,  one  inch  behind  the  tarsal  end  of  the  metatarsal  bone,  as  in 
plate  7,  fig.  4.  The  surgeon  makes  a  slightly  convex  incision  across  the 
hack  of  the  foot  from  one  landmark  to  the  other,  or  one  and  a  half  inches 
in  front  of  the  malleoli.  This  incision  dividing  all  of  tin  soft  parts  to 
the  bones,  the  heel  being  fixed  upon  the  tabic,  the  Burgeon  draws  the 
foot  forcibly  downward,  which  puts  the  anterior  ligaments  upon  the 
stretch,  allows  the  knife  to  divide  them,  and  enter  readily  between  the 
articulating  surfaces — plate  7,  fig.  9.  Care  must  be  taken  to  keep  tho 
knife  behind  the  tubercle  upon  the  Bcaphoid  :  if  it  passes  in  front  of 
this,  the  joint  between  the  scaphoid  and  cuneiform  bones  is  opened, 
and  the  scaphoid  bone  is  left  on  the  wrong  side  of  the  stump.  When 
the  knife  has  passed  through  the  joint  tho  blade  is  placed  horizontal, 
as  in  tho  second  part  of  Lisfranc's  amputation;  and  whilo  grazing  the 
bones,  a  flap  is  formed  of  the  sole,  and  completed,  as  in  \\^.  8.  Fig.  10 
shows  the  appearance  of  the  stump  alter  section  of  the  plantar  flap, 
also  tho  position  of  the  dorsal  and  plantar  vessels  which  will  require 
ligatures.  Sutures  in  sufficient  number  attach  the  flap  to  tho  anterior 
wound,  and  are  especially  required  in  foot  amputations. 

Sgme'a  amputation  of  the  foot,  ox  the  tibio-tanal  disarticulation.     It 

is  sometimes  found  that  a  ball  in  its  passage  has  so  crushed  the  tarsal 
bones,  including  the  anterior  portions  of  the  astragalus  and  os  calei.-, 
that  the  removal  of  the  whole  foot  is  required.  In  examining  plate  7, 
fig.  1,  we  find  that  the  styloid  processes  of  tho  tibia,  -<.  and  fibula,  l>, 
project  downward  below  the  level  of  the  articulating  face  of  the  tibia, 
forming  a  box  or  groove  in  which  the  rounded  head  of  the  astragalus,  c, 
plays,  making  a  hinge-joint  of  this  articulation.  Powerful  internal  and 
external  lateral  ligaments  bind  the  malleolus  to  the  astragalus  and  os 
calcis.  The  anterior  and  posterior  ligaments  partake  of  the  capsular  va- 
riety, but  do  not  give  strength  to  the  joint.  To  amputate  by  the  method 
of  Syme,  after  administering  chloroform  the  circulation  through  the 
limb  i's  secured  either  by  compressing  the  femoral  artery  in  the  groin, 
or  by  an  assistant  placing  one  thumb  over  the  anterior  tibial  artery  as 
itruns  over  the  ankle,  midway  between  the  malleoli  (plate  17,  fig.  3,  a), 
and  tho  fingers  of  the  other  hand  over  the  course  of  the  posterior 
tibial  artery  (plate  18,  fig.  2),  as  it  runs  on  the  inner  side  of  the  leg 
and  midway  between  the  inner  edge  of  the  tibia  and  the  tendo  achillis. 
Two  incisions  are  then  made  in  tho  direction  of  the  lines,  c  c  c,  plate 
8,  fig.  1.  The  ends  of  the  malleoli  being  clearly  ascertained,  an  inci- 
sion through  the  skin  and  tendons  is  made  on  the  instep,  extending 
from  one  malleolus  to  tho  other.  The  direotion  of  the  knife  is  then 
changed:  the  heel  of  the  blade  is  placed  at  tho  termination  of  the  dorsal 
incision  under  the  tip  of  thecxtcrnal  malleolus,  and  passing  obliquely 


TIROGOFF's    AMI'I  f  ATION    OP    THE    FOOT.  475 

backward  under  the  sole,  is  continued  obliquely  upward  and  forward, 
fig.  1,  c  c  c,  to  meet  the  termination  of  the  dorsal  incision  under  the 
inner  malleolus.  The  foot  beiug  forced  downward,  using  the  heel 
upon  the  end  of  the  table  as  a  fulcrum,  the  tibial  joint  is  largely 
opened  upon  the  anterior  face,  the  lateral  ligaments  next  divided 
with  the  point  of  the  knife,  which  allows  the  head  of  the  astragalus 
to  glido  forward  (plate  8,  fig.  2),  leaving  the  articulating  face  of  the 
tibia  folly  exposed.  The  foot  if  still  further  depressed,  the  posterior 
ligament  divided,  and  the  attachment  of  the  tendo  aehillis  very  carefully 
separated  from  the  foot  by  cutting  it  away  from  the  posterior  surface 
of  the  os  Calais.  The  dissection  of  the  sole  in  the  line  of  flap  is  com- 
pleted by  thrusting  the  thumb  into  the  inferior  incision,  and  applying 
the  point  of  the  knife  between  the  thumb-nail  and  the  inferior  and 
lateral  surfaces  of  the  os  calcis.  When  the  foot  is  removed  it  will  be 
found  that,  however  closely  the  posterior  surface  of  the  os  calcis  is 
grazed,  the  skin  in  the  flap  corresponding  to  this  portion  is  always 
very  thin.  If  the  dissection  be  attempted  without  care,  the  flap  will 
be  perforated  during  this  step  of  the  amputation.  When  the  foot  is 
removed,  the  malleoli  are  sawed  off  smoothly  on  a  level  with  the  articu- 
lating face  of  the  tibia:  the  dorsal  and  plantar  arteries,  two  in  number, 
secured,  and  the  flnp  brought  forward  and  retained  by  sutures.  The 
objection  to  this  opera  I  ion  is  that  the  flap  forms  a  cup  from  that  por- 
tion of  the  heel  which  covered  the  calcis,  and  as  such  can  not  be 
brought  in  perfect  apposition  with  the  opposing  surface,  but  remains 
separated,  a  receptacle  for  blood,  pus,  etc.  The  leg  is  shortened  two 
inches  by  this  amputation. 

A  modification  of  the  tibio-tarsal  disarticulation,  introduced  to  the  pro- 
fession by  a  Russian  surgeon,  Pirogoff,  is  a  decided  improvement  upon 
the  plan  adopted  by  Syrue.  The  anterior  incision  extends  from  one  mal- 
leolus to  the  other,  ami  is  joined  by  an  incision  extending  obliquely 
backward  and  downward  under  the  sole.  The  joint  is  largely  opened 
from  the  anterior  surface  by  the  division  of  the  anterior  and  lateral  liga- 
ments. To  this  point  of  the  operation  it  has  differed  in  no  respect  from 
that  of  Syme,  except  thai  the  plantar  inoision,  runs  more  obliquely  back- 
ward j  from  this  point  the  differences  of  the  operations  become  apparent. 
After  the  astragalus  has  been  freed  from  the  tibia,  instead  of  dissecting 
the  tendo  aehillis  from  the  her],  the  >:nv  is  plaoed  directly  behind  the 
head  of  th  ■  .-»r-t r:itr:ilu.-.  and  the  os  calcis  is  divided  in  the  oblique  line  of 
the  plantar  incision.  The  malleoli  and  articulating  face  of  the  tibia  are 
then  sawed  off  obliquely,  so  that  when  the  flap  is  brought  upward  the 
oblique  face  of  the  calcis  will  be  brought  in  nice  apposition  with  the  ob. 
liquelycuf  tibia,  and  retained  in  immediate  juxtaposition  by 

sutures.     When  tl  me  united,  which  they  soon  do,  a  g 1 

solid  .-tump  is  formed,  which  readily  bean  the  weight  of  the  body,  and 


478  AMPUTATION    OF    THE    LBO. 

tho  leg  is  found  very  little  shortened  when  compared  with  tho  sound 
limb.  The  very  great  advantages  of  this  modification  is  the  moro  rapid 
performance  of  the  operation,  ohviating  the  tedious  dissection  of  the 
plantar  flap,  and  isolation  of  the  os  calcis.  with  division  of  the  tendo 
achillis.  It  also  loaves  no  cupped  flap  for  the  collection  of  secretions, 
and,  moreover,  tho  portion  of  the  r»?  cab-is  retained  adds  from  one  to 
two  inches  to  the  limb.  Piste  B,  fig.  3,  shows  the  appearance  of  die 
wound  after  amputation  with  solid  inferior  flap,  and  fig.  1  indicates  the 
appearance  of  the  stump  after  cicatrisation  in  Pirogoff's  amputation. 
in  the  after-treatment  of  this  amputation  it  must  not  be  forgotten  that 
until  the  skin  has  firmly  cicatrized,  and  the  bones  have,  in  a  measure, 
bi  come  united,  the  leg  should  be  kept  somewhat  flexed  upon  the  thbgh; 
otherwise  the  constant  contraction  of  the  tendo  achillis  would  displace 
the  remaining  portion  of  the  08  ealeis  from  its  apposition  with  the  tibia, 
and  prevent  immediate  consolidation.  After  all  amputations  of  the  foot, 
should  tho  stump,  when  cicatrization  is  complete,  be  found  too  much 
drawn  backward,  and  its  usefulness  thereby  interfered  with,  a  subeuta- 
neous  section  of  the  tendo  achillis  will  be  required  to  correct  the  position 
of  the  tarsal  bones. 


AMPUTATIONS  OF  THE  LEO. 


In  theBe  days  of  mechanical  ingenuity  and  perfect  artificial  limbs,  it 
is  matter  of  moment  to  leave  as  long  a  stump  as  possible  For  the  bitter 
support  of  an  artificial  leg.  Formerly  the  seat  of  election  for  amputat- 
leg  was  four  fingers'  breadth  below  the  inferior  border  of  the 
patella.  Now  we  operate  at  any  available  point  of  the  limb  The  cir- 
cular operation  is  the  one  usually  preferred  upon  the  leg.  In  amputat- 
ing immediately  above  the  ankle  some  difficulty  is  found  in  turning  up 
the  onff  of  skin  over  the  larger  ciroumference  of  the  conical  leg.  To 
facilitate  the  dissection  of  tho  flap,  a  perpendicular  incision,  two  inches 
long,  is  made  upon  the  anterior  surface  of  the  tibia,  commencing  over 
the  point  where  it  is  intended  to  divide  the  bono.  At  the  lower  extremi- 
ty of  this  incision  a  oirculat  cut  is  made  round  the  leg,  and  the  skin 
rapidly  dissected  from  the  musolee  by  lifting  the  two  anterior  naps  aa 
high  as  tho  perpendicular  incision  will  allow.  These  flaps  are  well 
drawn  back,  and  the  knitv,  held  obliquely  from  above  downward  and 
backward,  cuts  up  a  Hap  of  mn  toles  from  the  bach  of  the  leg.  This  pos- 
terior flap  is  dissected  upward  until  it  reaches  the  level  of  the  com- 
mencement of  the  perpendicular  incision,  when  the  remaining  and  Inter- 
osseous muscular  fibres  are  divided  by  passing  the  knife  first  circularly 
around  the  bones  at  the  base  of  the  flap,  and  then  between  the  two 
bones,  cutting  with  a  sawing  motion,  first  upon  tho  tibia,  then  upon  tho 


AMPUTATION    OF   THE    LEG.  477 

fibula.  To  complete  the  figure  of  8  movernont  between  and  around  the 
bones,  so  as  to  divide  all  of  the  muscles,  the  knife  must  be  first  thrust 
between  the  bones  from  above  downward,  then  from  below  upward.  A 
broad,  three-tailed  retractor  is  placed  between  and  around  the  bones  for 
the  protection  of  the  flaps,  while  the  bones  are  divided  by  the  saw. 
Plate  S,  fig.  5,  shows  the  appearance  of  the  open  stump  after  the  removal 
of  the  leg  through  its  lower  third,  by  the  method  of  Lenoir,  above  de- 
scribed:  a,  I),  the  two-pointed  flaps  dissected  upward.  /,  the  anterior 
tibial  vessels  lying  upon  the  anterior  surface  of  the  interosseous  mem- 
brane; d,  the  posterior  tibial,  and,  e,  the  peroneal  arteries,  will  all  re- 
quire ligation.  In  closing  the  flap  apply  points  of  suture,  first  to  the 
perpendicular  incision,  and  then  close  the  circular  portion  of  the 
wound. 

Amputation,  four  fingers'  breadth  below  tho  patella,  is  the  common 
site  chosen  for  amputating  the  leg — having  this  great  advantage  among 
the  poor  laboring  classes  who  can  not  procure  an  expensive  artificial 
limb  :  that  when  the  wooden  pin  is  worn  (plate  24,  fig.  6),  a  long  stump 
docs  not  protrude  behind,  much  to  tho  inconvenience  of  the  wearer. 
The  best  results  arc  obtained  from  tho  circular  amputation.  Chloroform 
is  administered,  and  the  lower  portion  of  the  body  of  the  patient  stripped, 
so  that  an  assistant  can  secure  the  circulation  through  the  limb  by  com- 
pressing the  femoral  artery  at  tho  groin,  under  the  middle  of  Poupart's 
ligament,  where  its  pulsation  can  be  readily  felt,  as  the  vessel  courses 
over  the  ridge  forming  the  acetabulum — plate  14,  fig.  6.  Should  there 
not  be  sufficient  help  present,  the  pad  of  a  screw  tourniquet  is  applied 
over  the  course  and  pulsation  of  the  femoral  artery,  and  tightened  suf- 
ficiently to  stop  pulsation  iu  the  vessel  below  the  tourniquet.  The  sur- 
geon, in  the  meantime,  Bees  that  all  the  instruments  which  he  may  have 
Deed  for  daring  the  operation  are  at  hand,  viz  :  an  amputating  knife, 
sufficiently  narrow  toward  the  point  of  the  blade  to  pass  between  the 
tibia  and  fibula;  a  stout  scalpel,  for  facilitating  the  dissection  of  the 
circular  flap  of  skin  (in  the  hands  of  a  careful  surgeon,  the  skin  can  be 
as  well  dissected  up  by  the  amputating  knife  — in  the  hands  of  oue  not 
familiar  with  the  use  of  a  long  knife,  the  hands  of  the  assistant  will 
be  in  serious  danger,  hence  the  scalpel  is  recommended  for  this  step 
of  the  operation);  a  saw,  tenaculum,  artery  forceps,  and  bone-pliers, 
which,  with  a  three-tailed  retractor,  ligatures,  and  a  surgeon's  needle, 
completes  the  necessary  instruments.     Two  assistant!  d:  on- 

to compress  the  artery  iu  the  groin  :  the  other  to  elevate  aud  retract 
the  flaps,  and  support  the  upper  portion  of  the  leg. 

The  point  of  Bection  of  the  bones  having  been  determined,  the  sur- 
geon kneeling,  with  right  hand  holding  the  knife  passed  under  the  limb 
to  be  removed,  places  the  heel  of  the  knife  on  the  anterior  surface  of 
the  leg,  reaches  three  inches  below  the  point"  where  the  bones  arc  to  bo 


I,  B  C1R<   I   I  All     AMl'l    1ATIHN     Of     I  1 

divided,  the  ]><-iiit  of  the  knit'.'  toward  lii.-*  shoulder,  end,  by  ■  ssiring 
motion,  watching  the  heel  of  the  knife  and  raising  himself  n«  he  onto, 
makes  h  circular  incision  around  the  lim  ndi  the  wri.-t  t>.  ■ 

straining  posture  t"  oomplete  » 1 1 «-  circle  >  p  of  the  knife,  it  is 

oompleting  three-quarters  of  Lb<  section,  to  ■ 
sition  of  the  knife,  and  placing  th<'  heel  ol  the  blade  al  the  point  when 
the  incision  iras  commenood,  cut  in  s  saw  ing  i n ■  ■  t  j ■  ■ : i  acr  >ss  the  anterior 
surface  of  the  leg  t"  Join  the  tiret  incision  where  left  off.     The  skin  is 
now  drawn  upby  thefingers  of  the  left  hand,  or  by  a  forceps,  when,  with 

i  ir.'in  its  cellular 
tions  with  tin'  muscles,  so  that  the  surgeon  can  turn  it  up,  cuff- 
like.     Onoe  rolled  over,  it  i.-  only  neoessary  to  apply  the  e<t^«-  of  the 
scalpel   to  the  cellular  tissue  at   the  fold  of  the  everted  .-kin.  as  the 
■  iii  draws  it  upwards,  when  it  can  be  rapidly  d  the  rc- 

quired  height  The  long  knife  now  being  resumed,  the  operator  places 
himself,  with  bended  knee,  in  the  tir.-t  position  (plate  B,  ti^'.  8), 
and  commencing  n  second  incision  on  a  level  with  tlio  cuff-like  Hap, 
cuts  boldly  throngh  tlie  muscles  to  the  bone  in  passing  around  tlio 
entire  limb,  :<<  before.     The  soft  parts  t»'in^  drawn  backward  by  the 

1 1 1 j ir <  r -   of  an   Msistaol    thrust    i 1 1 1 •  •   the   WOUnd,   the  Itching 

i  the  tin  . 'i-r.-  of  the  assistant,  rtion  of 

the  blade,   which   i.-  osually  double-edged,  throngh   th<   inter 
space  from  below   upward,  cutting  with  s  ition  on  es 

in  tarn.  When  all  of  the  muscular  Bbres  on  the  inferior  portion  of  the 
limb  have  been  divided,  the  knife  Is  withdrawn,  to  be  thrust  b 

in  above,  to  oomplete  the  section  of  the  muscles  which  had, 
t ■  j •  to  this  time,  escaped.  When  the  bones  are  completely  bared,  o  three- 
tailed  retractor  plate  B,  Bg.  7,  ■<  a)  is  applied  to  the  stump,  the  centre 
tail  passed  betw<  en  the  bones,  the  outer  strips  folded  on  the  outer  and 
inner  side  ol  the  stump,  and  the  whole  retracted  so  that  the  soft  parti 
will  be  protected  from  the  sen  - 

mmencing  the  division  of  the  bones,  Bi  the  heel  of  the  saw  upon 
the  anterior  surface  of  the  tibia,  by  enoloaing  it  between  the  Btump  and 
the  left  thumb-nail  of  the  operator,  and  tan  very  obliquely  for  a  few 
strokes,  cutting  the  ores!  of  the  tibia  obliquely  for  three  quarto  i 
inch  ;  the  heel  ol  the  saw  Is  then  placed  el  right  angles  to  the  bone, 
one-quarter  of  an  Inch  below  the  firs)  section,  and,  fixed  In  position  by 
the  thumb-nail,  oommenoei  i"  groove  anew  the  tibia.  After  entering  the 
BubBtanoe  of  the   tibia,  the  saw  Is  so  elevated  "r  depressed,  depending 

upon  the  limb  operated  upon,  as  t ipleto  the  division  of  the  fibula 

first,  and  then  finishing  the  section  of  the  tibia.     The  object  of  making 
pine  of  the  tibia  was  to  remoi  e  t hi>  sharp 

prominence  of  l ,  and  prevet  I  ulceration  through  the 

flap.  An  examination  of  plate  6,  ii lt.  8,  will    how  the  position  and  aum- 


FLAP   AMrUTATION    OF   LEG.  479 

bcr  of  tbe  vessels  requiring  ligation,  viz  :  anterior  and  posterior  tibial, 
peroneal,  aud  sural  arteries.  At  times  tbe  section  of  tbe  bones  is  made  SO 
near  the  head  of  the  tibia,  or  the  popliteal  runs  so  low  down  before  it  bi- 
furcates, that  but  one  artery  requires  ligation — the  inferior  portion  of  the 
popliteal,  above  the  origin  of  tibial  and  sural  vessels.  One  end  of  each 
ligature  is  cut  off,  and  the  remaining  thread  secured  upon  the  outside 
of  the  leg  by  a  piece  of  adhesive  plaster,  and  the  lips  of  the  skin  flap 
kept  in  apposition  by  means  of  a  sufficient  number  of  sutures.  A  cold 
wet  cloth,  frequently  renewed,  is  all  the  dressing  required. 

The  flap  amputation,  when  preferred,  is  performed  as  follows  :  The 
point  where  the  bones  are  to  be  sawed  having  been  determined,  and 
similar  arrangements  having  been  made  as  in  the  circular  amputa- 
tion for  controlling  the  circulation  through  the  femoral  artery,  a 
convex  incision  is  made  upon  the  anterior  surface,  extending  from 
the  outer  border  of  the  fibula  to  the  inner  border  of  the  tibia,  about 
half  an  inch  below  the  point  of  section  in  the  bone.  As  the  tibia 
lies  very  superficially  upon  the  anterior  portion  of  the  leg,  the  incision 
is  only  skin-deep — plate  9,  fig.  2,  g  h  k.  As  soon  as  this  small  anterior 
flap  is  traced,  the  surgeon,  standing  on  the  inner  side  of  the  leg,  if  he 
is  operating  upon  the  right  limb,  thrusts  along,  sharp,  narrow  kuife 
iDto  the  calf,  directly  under  the  inner  border  of  the  tibia,  at  the  termi- 
nation of  the  anterior  incision,  and  passing  horizontally  through  the 
limb,  taking  care  to  keep  the  knife  immediately  behind  both  bones, 
makes  the  point  protrude  at  the  commencement  of  the  anterior  in- 
cision on  a  level  with  the  posterior  face  of  the  "fibula — plate  9,  fig.  1. 
Fig.  4,  d  t  <j,  defines  the  position  of  the  two  incisions.  The  surgeon 
cuts  down,  parallel  with  the  two  bones,  for  a  defame  of  three 
.  when  the  edge  of  the  blade  is  turned  obliquely  backward,  and 
cuts  out  the  long  posterior  Bap.  The  anterior  flap  is  separated  from 
its  deeper  parts  For  half  an  inch,  and  the  knife  is  then  thrust  between 
the  bones  both  from  above  downward  and  from  below  upward,  cutting 
alternately  upon  each  bone,  and  then  making  a  circular  incision 
around  tbe  bone-,  in  order  to  divide  the  interosseous  ligament  and 
all  remaining  muscular  fibres*  not  included  in  the  flaps.  The  two 
flaps  arc  then  well  drawn  back  by  an  assistant,  who  uses  cither 
his  hands  clasping  the  stamp,  or  I  three-tailed  retractor,  and  the 
inrgeon  applying  the  heel  of  the  saw  held  obliquely  to  the  bono, 
and  fixing  it  between  bit  thumb-nail  and  the  anterior  flap,  cuts  to  the 
depth  of  half  an  inch.  IK-  then  places  the  heel  of  the  saw  one-third 
of  aii  inch  lower  down,  at  right  angles  to  the  bone,  and  with  rapid 
to  and  Iro  motion-,  without  bearing    too  heavily  upon   the  saw.   divides 

partially  the  tibia,  and  completes  the  section  of  the  smaller  bone,  the 
fibuln,  before  the  tibia  is  completely  divided.     Four  arteries  usually  re- 


480  H.A1'    AMPUTATION    OF    LI 

quire  ligation  :  the  anterior  tibial,  between  the  tibia  and  fibula,  upon  the 
anterior  surface  of  the  interosseous  membrane,  and  three  vessel?  in  the 
posterior  flap,  viz :  the  posterior  tibial)  peroneal,  and  sural  vessels. 
When  the  heavy,  voluminous  posterior  flap  is  brought  over  the  surface 
of  the  bone  t"  be  covered,  it  is  always  found  s.i  thick  that  it  has 
to  be  puckered  and  even  stuffed  into  the  cavity  of  the  stump,  to  make 
the  rounded  margin  adapt  itself  to  the  small  cutaneous  anterior  flap. 
The  irregular  adaptation  is  often  the  oause  of  a  failure  in  obtaining 
qniok  union,  and  the  stump  heals  usually  by  the  slow  process  of  granu- 
lation and  suppuration.  As  the  size  of  the  posterior  flap  is  tho  only  sori- 
ous  objeol  ion  to  this  otherwise  good  operation,  il  can  be  readily  overcome 
by  laying  the  flap  upon  the  palm  of  the  left  hand  before  the  arteries 
are  tied,  which  will  make  the  mass  of  muscles  rise  in  a  ridge  in  the 
centre  of  the  flap,  when,  with  a  sharp  knife,  a  heavy  steak  is  taken 
from  the  face  of  the  flap,  which  reduces  it  to  a  thin  layer  of  muscular 
tissue  and  skin.  In  this  condition  all  objections  to  the  posterior  flap 
from  size  and  weight  are  removed,  as  it  will  now  adapt  itself  perfectly 
to  the  anterior  flap,  and  make,  in  every  respect,  a  creditable  stump. 

Sutures   and  a  wet  cloth  complete  the  dressing. 

In  using  an  artificial  limb,  after  an  amputation  of  the  l< 

ure  of  the  false  limb  u  nol  allowed  up  m  the  cicatrix.  l>ut  is  borne 
chii-Uy  by  the  lower  border  of  the  patella  and  condyles  of  the  femur, 
the  support  being  extended  upon  the  thigh,  and  in  some  ine 

to  the  trunk.     In  the  use  of  the  oo mm  in  wooden  pin,  as  seeu  in  plate 
21,  fig.  (>.  the  stump  is  ben)  at  ri-Jit  angles  to  the   thigh,  and  the  entire 
re   is   applied  to  the  knee — the  stump,  untrammelled,  jetting   be- 
hind the  apparatus. 

In  amputating  at  the  knee-joint,  one  of  two  methods  may  be  adopted. 
In  one,  the  knife  is  drawn  directly  across  the  knee  below  the  patella 
|  plate  9,  li::.  I  |,  the  incision  :Lt  once  passes  through  skin,  lie-amentum,  pa- 

tollsB,  and  capsule,  entering  boldly  into  the  knee-joint,  and,  severing  the 

strong  internal  and  external  lateral  ligaments,  travei-c-  the  entire  ar- 
ticular surface.  As  soon  as  the  head  of  the  tibia  can  be  luxated  for- 
ward, the  blade  is  placed  behind  this  bono,  and  grazing  its  posterior 
surface  in  its  desoent,  cuts  a  posterior  flap — plate  9,  fig.  4,  «  b  <•.  While 
the  perpendicular  portion  of  the  posterior  flap  is  being  made,  which 
should  be  about  three  inches  long,  the  assistant  might  thrust  his  hand 
into  the  wonnd  and  secure  the  popliteal  artery.  Alter  ligation  of  all 
bleedin  most  of  which  will  be  found  in  the  posterior  flap,  the 

Boft coverings  for  the  head  of  the  femur  will  be  retained  in  position  by 
a. sufficient  number  of  sutures. 

As  this  posterior  flap  operation   has  the   same  objection   which    was 
urged  to  the  posterior  flap  In  amputations  in  the  upper  third  of  I 
surgeons  have  reversed   the  position    of  the  flap,  taking  it  solely  from 


AMPUTATION    OF   THIGH.  481 

the  skin  upon  the  anterior  surface  of  the  leg — plate  9,  fig.  5.  The  land- 
marks about  tho  knee-joint  having  been  determined,  an  incision  is  com- 
menced upon  the  outer  face  of  the  tibia,  just  below  tho  centre  of  tho 
external  condylo  of  the  femur.  After  descending  vertically  for  three 
inchos,  the  knife  sweeps  in  a  convex  incision  across  tho  anterior  surface 
of  the  log,  and  is  continued 'upward  on  the  inner  side  of  the  leg,  in  a 
similar  perpendicular  incision  of  equal  length,  terminating  below  tho 
centre  of  the  inner  condyle — plate  9,  fig.  b,  a  b  c.  This  flap  of  skin  is 
dissected  up  from  the  face  of  the  tibia,  t,  and  everted,  cuff-like,  is  drawn 
over  tho  lower  anterior  extremity  of  tho  femur,  until  the  base  of  the 
fold  exposes  tho  anterior  ligament  of  the  kneo-joint,  when  tho  knife 
cuts  directly  into  and  through  it,  completing  tho  removal  of  tbo  log  by 
making  a  circular  incision  directly  backward  in  the  Hue  of  the  joint. 

This  is  the  bettor  operation  of  tho  two  flap  disarticulations,  as  the 
oioatricial  line  is  placed  behind  the  limb,  whoro  it  will  ho  comparative- 
ly protected.  When  the  cicatricial  lino  lies  on  tho  anterior  faco  of  tho 
stump,  it  is  liable  to  frequeut  and  painful  injury. 


AMPUTATION  OF  THIGH. 

In  the  thigh,  as  in  the  amputation  of  every  portion  of  either  limb, 
the  surgeon  has  the  choice  of  oithor  circular  or  flap  methods — the  flaps 
being  mado  in  au  astero-posterior,  lateral,  or  obliquo  direction,  as  the 
iv  require  iw  the  fancy  of  the  surgeon  suggest.  As  has  been  be- 
fore stated,  the  circular  method  is  nowgeucrally  preferred  by  most  opera- 
tors, especially  those  who  have  not  had  much  experience  in  the  removal 
of  limbs,  inasmuch  as  the  circular  flap  of  skin  is  much  more  likely  to  bo 
ample  tha n  where  flaps  are  cut,  which,  in  the  hands  of  the  inexperi- 
enced, arc  always  made  too  short.  In  examining  tho  reported  lists 
from  tho  Surgeon- General's  office  it  is  found  that  of  917  capital  ampu- 
tation! where  the  method  adopted  was  reported,  562  woroby  the  circular 
method,  an'l  355  were  flap  amputations.  Of  233  amputations  of  the 
thigh,  131  were  by  tho  circular  method.  These  figures  .-how  clearly 
the  preference  given  to  the  circular  oVer  the  flap  operation. 

Fl'ip  amputation. — Where  the  surgeon  shows  a  preference  for  the  flap 
ni(  t  bod,  he  stands  in  such  a  way  that  he  can  seize  the  muscles  upon  the 
anterior  portion  of  the  thigh  with  his  left  hand,  and  while  a  careful  Assist- 
ant compresses  the  femoral  artery  in  the  groin  where  it  courses  over  the 
pubic  bono,  ■  long,  narrow,  sharp-pointed  knife  i?  plunged  into  the 
lateral  surface  of  the  leg.  and  oonthiuot  its  onward  progress  nn'il  it 
00 


182  i  IRCl  LAB    AMPUTA1  [ON    OJ    I  BIOH 

strikes  tbc  centre  of  the  lateral  surface  of  the  femur.  Depressing  the 
handle,  he  continues  the  onward  movement  of  the  knife  until  it  glides 
over  the  anterior  face  of  the  hone,  when  i  •  igbtly  the  handle, 

and  pushing  the  knife  directly  forward  across  the  limb,  the  point 
appears  through  the  skin  on  the  0]  •   of  the  thigh,  when   tho 

knife  will  have  fully  one-half  the  thickness  of  the  limb  u i>'«n  the  blade. 
Grazing  the  femur,  the  operator  outs,  directly  downward  until  ho  has 
sufficient  length  of  1 1  n j > .  when  he  turns  the  edge  of  the  blade  outward  and 
completes  tho  flap.  The  flap  being  now  held  up  l.y  an  assistant,  the  point 
of  the  knife  is  again  entered  a  little  lower  down  than  before,  through 
the  cut  muscular  surface,  and  parsing  under  the  femur,  appears  again 
through  the  cut  muscular  surface  on  the  opposite  side  of  tho  limb — 
plate  10,  fig.  1.  The  object  of  passing  the  kuifo  through  the  muscles  El 
to  avoid  cutting  the  skin  irregularly  at  the  point  of  trausli.xion.  The 
posterior  surface  of  the  femur  is  grazed,  as  vas  its  anterior  in  the  tirst 
stop  of  tho  amputation,  and  when  a  sufficient  length  of  flap  Iim*  been 
formed,  cuts  directly  outward.  The  two  flaps  are  drawn  hack  bjf  an 
assistant,  the  Burgeon  sweeps  the  knife  around  the  bono  at  tin  ; 
the  Haps  to  divide  all  muscular  fibres  oot  se?<  n  d  in  the  cutting  of  the 
ii;i] is,  and  then  applies  the  saw  to  the  femur  as  high  up  as  possible, 
fixes  the  heel  of  the  blade  between  the  nail  of  bis  left  thumb  and  the 
base  of  the  flap,  and  drawing  it  Bteadily  toward  him,  readily  groove^ 
a  passage  for  it  upon  tho  bone.  Should  the  limb  not  be  steadily  held 
during  the  sawing,  any  sharp  spioula  of  bone  left  by  tho  snapping  of 
the  femur  must  be  removed  by  the  bone  forceps. 

In  locating  tho  flaps,  the  knife  should  be  BO  directed  that  the  femoral 
artery  escapes  the  first  section,  and  is  found  at  the  base  of  the  second 
or  posterior  flap — plate  10,  fig.  2.    The  length  of  the  Haps  must  depend 

upon  the  size  of  the  limb.     A  g 1  rule  is  to  make  them  ample,  eveij 

larger  than  may  be  required  :  retraction  and  contraction  of  the  Map 
will  soon  remove  all  excess,  when  a  too  closely  fitting  flap,  by  II 
ening,  may  bo  so  drawn  over  the  eud  of  the  bone  as  eventually  to 
cause  its  exposure  and  protrusion.  One-fourth  the  circumference  of 
tho  limb  would  make  a  sufficiently  ample  flap — if  the  thigh  be  twenty 
inches  in  circumference,  the  flaps  should  be  five  inches  long.  When 
nicoly  cut  and  properly  attached  hy  sutures,  they  adjust  themselves  as 
porfcotly  as  the  two  valved  shells  of  an  oyster. 

In  the  circular  amputation  many  methods  may  also  bo  adopted. 
The  circular  flap  of  skin  may  either  be  'li  IBOOted  up,  cufT-like,  for  four 
or  live  inches,  when  all  of  the  remaining  soft  parts  are  severed  perpen- 
dicularly to  tho  bone;  or  the  following  course  may  be  adopted:  Having 
chloroformed  the  patient  and  secured  the  circulation  through  the 
femoral  artery,  either  by  preBBuro  at  the  groin  or  by  means  of  a  tour- 


AMPUTATION    AT    HIP-JOINT. 


483 


niquet,  a  circular  incision  is  mndo  around  the  thigh  from  four  t°  f,ve 
inches  below  the  point  at  which  it  is  designed  to  saw  the  boue.  To 
effect  this  circular  incision  the  surgeon  kneels,  and  passing  his  arm 
undor  the  limb  to  bo  amputated,  bends  tho  wrist  so  as  to  place  the  heel 
of  the  blade  on  tho  anterior  face  of  the  limb,  the  point  of  the  knife 
nearly  touching  tho  right  shoulder  of  the  surgeon.  With  a  sawing 
motion  ho  commences  the  incision,  and,  watching  the  heel  of  tho  knifo 
as  he  rises,  may,  by  flexing  forcibly  tho  wrist,  complete  the  circuit  of 
the  member.  This  position  being  a  forced  one,  however,  it  is  prefer- 
able, after  cutting  three-fourths  of  tho  cireumferenco  of  the  limb,  to 
change  the  position  of  the  knife.  Placo  the  blado  over  the  member 
with  tho  point  looking  away  from  the  operator,  and  commencing  tho 
second  incision  in  tho  line  traced  at  first  by  the  knife,  complete  tho 
circle  by  ending  where  the  first  incision  left  off.  The  skin  being  equal- 
ly retracted  by  an  apt  assistant,  will  cause  the  gaping  of  the  wound  for 
nearly  an  iuch.  The  knife,  placed  again  in  the  same  position  as  at  first, 
follows  the  upper  lino  of  the  retracted  skin,  cutting  through  all  of  tlio 
muscles.  This  enables  tho  assistant  to  retract  the  soft  parts,  leaving 
from  two  and  a  half  to  threo  inches  of  gaping.  A  third  incision,  fol- 
lowing as  before  the  upper  contour  of  tho  cutaneous  incision,  dividos 
for  a  third  time  the  muscles,  permits  of  ample  retraction  of  tho  soft 
parts  to  make  a  large  conical  flap,  and  at  the  same  time  isolates  tho 
shaft  of  the  femur,  preparing  it  for  the  saw— plate  10,  fig.  3.  A  ro- 
tractor,  in  this  figure,  composed  of  a  slit  piece  of  cloth,  protects  the 
soft  parts  from  being  injured  by  the  saw.  The  flap,  before  it  is  closed, 
represents  an  inverted  cone,  the  cut  surfaco  of  tho  bone  forming  the 
truncated  apex,  while  the  retracted  muscles  form  the  sides  of  the  cone 
(plate  10,  fig.  l),  having  the  skin  as  a  base.  This  is  one  of  the  best 
methods  of  amputating,  giving  excellent  results,  as  the  circular  flap,  tho 
edges  of  which  arc  composed  solely  of  skin,  shows  a  strong  disposition  to 
heal  by  quick  union.  The  bono  is  so  well  covered  that  a  conical  stump 
rarely  results  from  this  operation,  while  at  the  same  time  there  is  no 
excess  of  muscle  in  the  flap  to  induce  suppurative  inflammation. 

Amputation  at  the  hip-joint  is  an  operation  so  serious  in  its  re. 
nearly  every  case  being  fatal — that  it  is  a  question  whether  its  per- 
formance should  not  be  confined  to  the  amphitheatre  Military  .-ur- 
geons  have  at  times  thought  the  operation  called  for.  and  have  per- 
formed it  with  invariably  the  same  fatal  result ;  so  that  the  question  is 
often  forced  upon  them  whether  ii  would  not  be  preferable  t<i  leave  t ht- 
patient  to  bis  fate,  which,  under  no  condition,  can  be  mure  serious  than 
the  operation.  There  is  an  unfortunate  ambition — we  might  even  use  a 
■tronger  term  for  it — a  criminal  desire  to  have  an  amputation  at.  the 
hip-joint  in  the  lis)     F  o|  rfurmed,  which  misleads  many  sur 


1M       .  AMPUTATION    AT    HIP-JOINT. 

gcons  to  perform  this  disarticulation,  when  their  bolter  judgment  tench- 
es them  that  it  must  be  a  useless  mutilation.  Most  that  can  be  said  in 
its  favor  is  that  i'  relieves  the  wounded  of  a  lingering  death,  as  it 
hastens  this  issue.  As  one  ease  of  primary  amputation  at  the  hip-joint 
during  this  war  has  recovered,  and  as  a  limb  may  be  so  torn  off  or  exten- 
sively mutilated  that  the  operation  may  be  justifiable— even  as  a  very 
temporary  measure — to  relieve  the  wounded  man  of  a  mangled  limb, 
the  method  of  performing  the  disarticulation  will  be  given. 

Plate  10,  fig.  5,  indicates  the  relative  position  of  tho  pelvic  bone-  with 
the  femur,  and  shows  where  the  head  of  the  thigh-bono  hides  itself  in 
the  deep  acetabulum.  Amputating  by  tho  double  flap  is  found  the  most 
convenient  method.  To  form  the  anterior  flap,  if  tho  amputatiou  be 
performed  upon  the  left  thigh,  the  limb  being  slightly  flexed  and  ab- 
ducted, a  long,  sharp,  narrow  knife  is  entered  from  the  outer  side  of  the 
thigh  immediately  above  the  upper  and  outer  border  of  the  great  tro- 
chanter, and  is  carried  directly  inward  until  it  strikes  the  neck  of  the 
lemur.  The  handle  of  the  knife  is  then  slightly  depressod  to  allow  the 
point  to  glide  over  the  junction  of  the  head  with  the  neck,  cutting 
through  the  capsule.  The  direction  of  the  knife  must  now  be  changed, 
otherwise  the  point  would  pass  into  the  abdi  minal  cavity.  The  handle 
should  bo  carried  upward  and  forward,  whioh  depresses  the  point  and 
allows  it  to  make  its  appearance  on  the  inner  side  of  the  thigh,  one 
inch  iu  front  of  and  below  the  ischial  tuberosity — plate  10,  fig.  5.  Tho 
heel  of  the  knife  cuts  downward  in  the  direction  of  c  b,  grazing  tho 
hone,  and  is  followed  by  the  hand  of  an  assistant  thrust  into  tho 
wound  and  securing  the  femoral  artery.  Tho  flap  is  completed  by 
cutting  out  in  the  direction  n  /,.  This  flap  is  then  drawn  upward  upon 
the  abdomen  1>.\  the  assistant,  who  secures  the  vessels  by  pressure;  tho 
thigh  is  carried  downward,  backward,  and  outward,  which  causes  the 
head  of  tho  femur  to  stretch  the  anterior  portion  of  the  capsule  ;  an 
incision  directly  across  this  releases  the  bead,  which,  as  the  ligamen- 
tum  teres,  the  round  ligament  attaching  the  head  of  the  femur  to  tho 
cotyloid  cavity,  is  severed,  escapes  from  the  acetabulum,  with  a  strik- 
ing noise. 

The  amputation  is  completed  either  by  passing  tho  knife  behind  the 
neck  of  the  femur  and  cutting  a  flap  obliquely  downward  and  back- 
Ward,  corresponding  to  the  line  of  anterior  incision,  or  this  flap  can  bo 
made  by  cutting  from  without  inwards,  as  follows  :  the  operator,  kneel- 
ing, passes  the  heel  of  the  amputating  knife  on  tho  inner  sido  of  tho 
thigh,  and,  commencing  an  incision  from  the  inner  angle  of  tho  ante- 
rior flap,  cuts  obliquely  downward  and  outward  until  a  flap  of  suffi- 
cient length  is  made,  when  he  brings  tho  heel  of  the  knife,  with  a 
sawing  motion,  across  the  limb,  then  upward  and  outward  to  terminate 
the  incision   at  the  point   of  transfixion.     The  capsular  ligament   and 


RULES   FOR   RESECTION.  485 

remaining  muscles  in  the  vicinity  of  tlic  joint,  attaching  tbo  thigh  to 
the  trunk,  arc  divided  from  above  backward.  The  large  arteries  re- 
quiring ligation  arc  the  femoral  and  its  profunda  branch,  which  are 
on  the  inner  side  of  the  anterior  flap,  accompanied  by  their  veins,// 
(plate  10,  fig.  7).  The  bleeding  vessels  in  the  posterior  flap  are  com- 
paratively small  muscular  branches.  As  the  patient,  during  this  oper- 
ation, often  dies  from  the  loss  of  blood,  it  has  been  recommended  to 
ligato  all  bleeding  vessels  in  the  anterior  flap  before  the  section  of  the 
posterior  flap  is  commenced.  The  closure  of  the  wound  by  sutures, 
and  the  subsequent  cold  water  dressing,  is  common  to  all  amputations. 


RESECTIONS. 


i?e*eo/?'o»s  of  the  heads  of  bones  are  offered  as  a  substitute  for  ampu- 
tations. Experience  in  military  surgery  has  shown  that  when  a  ball 
pasnes  through  a  large  joint,  crushing  the  heads  of  the  bones,  it  pro- 
duces a  very  serious  lesion,  which,  without  an  operation,  would  be 
classed  among  the  mortal  wounds.  Attempts  at  treatment,  without  the 
use  of  tho  knife,  would  in  most  cases  terminate  fatally;  and  even 
where  the  life  was  saved,  the  limb  would  be  a  stiff  and  useless  one.  So 
aware  were  surgeons  of  the  little  success  following  the  treatment  of 
such  joint  injuries,  that  they  had  established  the  rule,  of  amputating 
in  all  such  wounds.  Conservative  surgery  has  introduced  resections  as 
a  very  decided  improvement  over  amputations,  inasmuch  as  it  not  only 
saves  the  limb,  thus  protecting  the  patient  from  the  fatality  of  ampu- 
tation, but  leaves  him  with  a  very  useful  extremity. 

Although  the  resection  of  each  joint  has  its  peculiarities,  there  are 
certain  rules  in  the  performance  of  the  operation  common  to  all  resee- 
One  of  these  is,  that  the  joint  should  always  be  opened  iu  such 
away  as  to  avoid  all  of  the  large:  vessels  and  nerves.  As  these 
always  run  over  one  face  of  the  articulation,  the  incisions  necessary  to 
expose  the  heads  of  the  bones  should  always  be  made  upon  the  oppo- 
site surface.  Straight  incisions  are  usually  preferable  to  flaps,  as  the 
s  are  not  cut  up,  and  therefore  their  action  not  paralysed,  as  is 
usually  the  case  in  flap  operations.  The  perpendicular  incision  should 
always  be  made  ample,  to  expose  perfectly'  the  heads  of  tbo  bones,  and 
give  room  for  manipulation:  a  free  incision  expedites  the  reBCCtion,  fa- 
cilitating every  step  of  the  operation.  When  this  incision  is  loo  short 
the  movements  of  the  operator  are  very  mnoh  cramped,  especially  as 
regards  the  ligation  of  divided  vessels,  the  isolation  of  tho  bones,  and 
the  eversion   of  their  extremities.     This  straight  incision  should  pass 


186  ItKSl  CTTON    OP    l  lir.    r.OWI  i:    .TAW. 

>-  to  the  bone  by  a  single  stroke  of  the  knife,  and  the  head  of  the 
bones  isolated  by  dissecting  up  from  the  bone  all  the  muscles  :md  peri- 
osteum also  with  it.  if  possible.  By  keeping  the  point  of  the  knit'«'  grts> 
ing  the  bone,  the  main  blood-vessels  and  nerves  running  through  the 
soft  parts  are  not  disturbed.  All  tendons  running  over  the  joint  t"  sup- 
plj  distant  parts  must  be  carefully  drawn  aside,  and  not  divided. 
Usually  it  is  found  most  convenient  to  torn  the  head  of  the  bone  out  of 
its  socket  before  the  saw  is  used.  To  effect  this,  all  of  the  musoles  and 
ligaments  whieh  are  attached  around  the  neck  of  the  bone  must  bo  di- 
vided, which  can  only  be  safely  accomplished  by  rotating  forcibly  the 
shaft  inwards,  then  outwards,  which  will  bring  the  various  muscles  into 
the  straight  incision  and  under  the  point  of  the  knife.  In  isolating  the 
head  of  the  bone,  and  releasing  it  from  its  cavity,  the  point  of  the  knife 
should  never  get  out  of  sight,  as  important  parts  may  very  easily  be 
injured  by  the  point  buried  in  the  wound.  When  the  bead  of  the  bone 
has  all  of  its  connections  severed,  and  is  thrust  out  of  the  wound,  we 
should  place  behind  it  a  guard,  composed  of  a  strip  of  wood,  the  handle 
of  a  knife,  or  the  blade  of  a  spatula,  to  protect  the  soft  parts  while  the 
saw  is  dividing  the  neck  of  the  bone. 

In  gunshot  wounds,  as  the  head  is  often  crushed  from  the  shaft,  the 
portion  remaining  in  the  articulating  cavity  must  be  seized  with  a 
strong  tooth  forceps,  so  as  to  obtain  a  leverage  upon  it,  and  by  rotating 
the  extremity  the  capsule  and  muscles  can  bo  divided,  and  the  head 
withdrawn.  The  section  of  the  shaft  should  always  be  horizontal,  so  as 
to  offer  a  smooth,  broad  surface  to  the  articulating  surface  above. 
Where  the  head  of  a  bone  has  been  fractured,  the  extremity  of  the 
shaft  must  be  cut  so  as  to  leave  a  smooth  surface.  All  small  vessels 
divided  during  the  operation  must  be  ligated,  and  the  wound  closed  by 
sutures,  the  limb  placed  in  an  easy  position,  ami  cold  water  dressings 
applied. 

Union  by  the  first  intention  is  not  expected  for  the  entire  wound. 
A  portion  of  it  will  heal  rapidly,  leaving  an  opening  for  the  escape  of 
the  secretions  from  within  the  cavity.  During  the  treatment  the  inner 
surface  of  the  wound  will  usually  suppurate  profusely,  and  small  par- 
ticles of  bono  may  become  detached  from  I  he  sawed  extremities.  Fi- 
nally, ligamentous  bauds  unite  the  opposing  surfaces  of  the  bones ;  and 
while  all  of  the  movements  of  that  portion  of  the  extremity  beyond 
the  part  resected  arc  preserved,  the  now'  joint  regains  in  time  many 
useful  movements. 

Rbbbction  of  tiik  LOWBB  jaw  is  commenced  by  drawing  out  the 
incisor,  or  canine  tooth,  corresponding  t"  that  portion  of  the  jaw  to 
which  the  saw  is  to  be  applied.  With  a  sharp-pointed  bistoury  an 
incision  is  made  along  the  base  of  the  jaw,  extending  from  its  angle  to 


RESECTTON    OF   TI1F.   LOWftR   JAW.  487 

the  point  of  section  of  the  bone,  which  is  usually  within  a  half-inch  of 
the  symphysis  menti,  or  median  line  of  the  chin.  This  incision  ex- 
tends to  the  bone,  and  as  it  divides  the  facial  artery,  in  its  course  over 
the  face,  in  front  of  the  massoter  muscle,  this  vessel  should  be  ;it  once 
tied.  The  next  step  of  the  operation  consists  in  isolating  the  gums  and 
floor  of  the  mouth  from  the  maxillary  bone  at.  the  point  where  the  sec- 
tion is  to  be  made.  When  the  finger,  from  the  outer  wound,  can  be 
passed  readily  into  the  mouth,  both  above  aud  below  the  bone,  the  low- 
er jaw  is  to  be  divided,  either  by  passing  a  chain-saw  around  the  bone 
and  with  steady  traction  sawing  it  through,  or  by  using  a  strong  Lis- 
ton  forceps,  which  requires  more  strength  in  the  hand  than  surgeons 
usually  possess:  or  by  placing  a  spatula  under  the  bone  for  the  protec- 
tion of  the  soft,  parts,  and  using  a  small  saw.  As  soon  as  the  section 
is  completed,  the  portion  of  the  lower  jaw  to  be  removed  is  drawu  forci- 
bly outward,  dividing  the  muscular  floor  of  the  mouth  attached  to  the 
mylo-hyoidean  ridge.  The  pterogoid  muscles  attached  to  the  inner 
face  of  the  ramus  are  divided ;  next  in  order  the  tendon  of  the  tempo- 
ral and  masseter  muscles  attached  to  the  outer  face  of  the  ramus  and 
coranoid  process.  Using  still  more  force  upjn  the  lever,  the  head  of 
the  lower  jaw  is  wrenched  from  its  glenoid  cavity  (plate  11,  fig.  1), 
leaving  a  few  ligamentous  bands  to  be  divided.  This  is  much  better 
than  burying  the  point  of  the  bistoury  in  the  depth  of  the  wound 
for  the  purpose  of  dividing  the  internal  ligaments  of  the  joint,  when 
it  will  be  nearly  impossible  to  avoid  injuring  the  internal  maxillary 
artery,  and  cause  annoying  hemorrhage.  Should  this  artery,  which 
runs  in  very  close  proximity  with  the  neck  of  the  jaw-bone,  be  cut,  it 
must  be  secured  by  ligature.  When  this  vessel  is  avoided  the  facial 
artery  is  the  only  one  severed.  Should  thero  be  much  oozing  from  the 
depth  of  the  wound  in  the  vicinity  of  the  glenoid  cavity,  the  surface 
should  be  painted  with  the  liquid  persulphate  of  iron.  When  the  (lap 
resumes  its  position,  and  is  kept  in  place  by  a  sufficient  number  of 
sutures,  healing  rapidly  takes  place,  and  very  little  deformity  ensues. 
If  the  operation  be  performed  upon  a  man,  his  beard  will  conceal  all 
traces  of  the  operation. 

Although  the  lateral  portion  of  the  inferior  maxillary  is  most  liable 
to  disease,  the  anterior  portion,  or  arch  at  the  symphysis  menti,  may 
become  carious  and  require  removal.  The  bone  is  readily  exposed  by 
an  incision  upon  the  median  line  of  the  chin  and  throat,  extending 
from  the  lip,  which  is  divided,  to  the  hyoid  bone.  Two  flaps  are  dis- 
sected up,  laying  bare  the  portion  of  bone  to  be  removed — plate  11,  fig. 
2.  One  tooth  is  drawn  from  each  m  le  of  the  mouth  corresponding  to 
the  points  of  notion,  and  the  bo  severed  either  by  the  use  of  the 
saw  or  Liston's  heavy  bone  foroeps.  In  the  removal  of  the  anterior 
ji  irtion  of  the  lower  jaw,  a"  the  muscles  which  protrade  t'1 


.  hi:    i  PPKR   JAW. 

;   from  their  points  of  attachment  on  the  inner  face  of  ti. 

menti.  the   retractor  muscles,   having   no  antagonistic 

tend  to  draw  the  tengue  backward,  whore,  recoiling  upon  the  larynx, 

and  pushing  down  the  epiglottis  upon  the  laryngeal  opening)  it  tbrcat- 

Sboation.      To  obviate  thia  the  tot  aculun 

and  drawn  forward.     When  the  flapa  ar< 

ed  through  the  phrenum  <>r  the  tongne,  trhioh  causes  it  to  ad- 
the  cicatricial  line,  and  the  teudoncj  ire  retraction 

is  corrected. 

I\  Tin:  bbbbctiom  OP  Tii i:  i  I'i'i.it  .? a  w,  a  somewhat  similar  proced- 
adopted.     The   relutii.nn  of  the   superior  maxillary  bone   are   M 
follows:  Upon  the  median  line  it  meets  the  opposite  superior  jaw-bon«j 
forming  with  it  the  roof  of  the  month:  its  ascending  |  Lttaohed 

to  the  oh  frontis,  08  unguis,  and  ethmoid;  externally  it  meets  with  the 
malar  bone,  posteriorly  with  the  palate  bone  and  pteregoid  plates  of  the 
sphenoid.     To  isolate  the  bone  it  must  be  separated  from  all  of  these 

A   simple    plan  "f  operation   consists   in    making  a    curved    incision 

ctending  through  the  entire  thickness  of  the  oheat 

from   the   sygoma  to  the  angle  of  the  month.     By  dissecting  up  this 

nppor  flap  from  the  face  of  the  upper  jaw,  the  entire  extent  of  tin-  bona 

can  be  readily  exposed-  -plate  11,  fig.  9.     Having  separated  the  nasal 

cartilage  from  the  oreseentie  louder  of  the  nasal  pi  to  open 

tl  cavity  through  the  wound,  one  of  the  incisive  teeth  is  drawn 

out.  and  a  heavy  Listen  foroeps  is  applied  to  the  jaw  to  sever  the  hard 

palate  or  roof  of  the  month.     One  blade  is  placed,  as  in  fig.  3,  Into  the 

mouth   in  th  icatod  by  the  extracted  tooth;  the  othei 

under  the  everted  flap  into  the  nostrils,  and  the  anterior  and  lateral 

oonneotion  of  the  bone  is   readily  cut  through.     The  fo 

applied  so  as  to  divide   the   nasal  process   with  the  attachment  to  the 

all  and  ethmoid.     To  effeof  thia  the  flap  ia  dl  lected  upward  an 

as  to  expose  tl rbital  eavily.     One  blade  of  the  forceps  ii  plaot  l  In 

the  upper  part  of  the  nostril,  the  other  into  the  inferior  portion  of  the 
orbital  oavity,  and  with  one  stroke  the  superior  connections  of  the  jaw 
are  severed.  Again,  one  blade  of  the  foroeps  is  placed  in  the  outer  and 
inferior  portion  of  the  orbit,  the  other  in  the  temporal  fossa  behiQd  the 
miliar  bone,  when  the  malar  oonnectiona  are  destroyed.  Should  the 
malar  hone  be  also  diseasi  d,  it  .-In. old  be  remov*  d  by  passing  the  blade 

Of  the  foioepa  first  into  ihe  outer  portion    of    tl rbit  and  the  temporal 

tbove  tin:  malar  bone,  and  afterward  severing  the  sygomatio  arch. 

The  Isolation  of  the  bone  la  completed  by  putting  a  chisel  upon  the 

floor  of  the  orbit,  and  driving  it  With  ■  mallet,  force  it  downward  and 

backward,  cutting  through  al  tha  Ural  blow  the  floor  of  the  orbit  and 

the  superior  maxillary  nerve  coursing  upon  it.     The  chisel  ia  forced, 


RESECTIONS    UPON    TIIF.    UPPER    EXTREMITY.        lv'' 

without  much  diflicnlty,  through  the  posterior  portion  of  antrum  until 
it  reaches  the  posterior  wall  of  the  maxilla,  and  finds  an  obstacle  in 
the  ptercgoid  plates.  Using  these  plates  as  a  fulcrum  or  bose,  the 
chisel  as  a  lever,  it  is  only  necessary  to  depress  the  handle,  when  the 
maxillary  bone  will  at  once  yield  and  be  luxated  from  its  position. 
The  soft  palate  alone  keeps  it  attached  to  the  skull,  and  this  can  be 
severed  either  by  using  a  eurved  scissors,  or  by  thrusting  a  .-harp- 
pointed  bistoury  into  the  mouth,  cutting  first  in  the  median  line  of  the 
roof  of  the  mouth,  and  then  making  a  transverse  incision  extending 
half-way  across  the  posterior  superior  wall  of  the  buccal  cavity,  two 
lines  in  advance  of  the  pendulous  portion  of  tbe  soft  palate.  Thebone 
is  then  grasped  in  a  strong  foreepB,  and,  being  turned  upon  its  axis,  ex- 
poses any  remaining  soft  parts  for  division. 

There  is  but  little  hemorrhage  from  such  an  operation.  The  superior 
maxillary  bone,  although  freely  supplied  by  many  small  vessels,  has  no 
large  artery  running  upon  it . ;  and,  moreover,  by  the  use  of  the  chisel  and 
bone  forceps  the  vessels  have  their  coats  so  crushed  that  they  partake  of 
the  character  of  contused  and  lacerated  vessels,  which  do  not  bleed. 
Any  oozing  of  blood  soon  ceases  upon  exposure  of  the  cavity  to  air. 
The  application  of  the  liquid  persulphate  of  iron  will  at  once  dry  the 
surface.  Although  the  cavity  looks  frightful  immediately  after  the 
operation,  the  closure  of  the  flap  leaves  but  little  deformity — plate  11, 
fig.  4.  From  the  vascularity  of  the  soft  parts  quick  union  is,  without 
difficulty,  obtained  under  cold  water  dressings.  The  sutures  are  removed 
by  the  fifth  day,  and  the  patient  is  nearly  well  by  the  end  of  the  first 
week.  It  is  a  practice  with  some  surgeons  to  stuff  the  cavity,  imme- 
diately after  the  operation,  with  a  piece  of  sponge  or  lint.  No  such 
stuffing  is  required  ;  on  the  contrary,  any  foreign  bodies  in  the  wound 
arc  detrimental.  Pus  is  secreted  from  the  cavity,  and  is  spit  up  some 
time  after  the  outer  wound  bas  completely  cicatrised. 


SECTIONS  l  PON  Till,  l  I'l'Kl:  t:\tkemity. 

Tin-  i  i  avi'  i  i    may  require  resection,  in   whole  or  in  part,  from  dis- 
MMd    action   in   the   bone,  brought  ,uela  of  gunshot   injury. 

iries  may  supervene,  accompanied  by  pain  and  a  constant 
and  annoying  discharge  of  pns  from  fistulous  orifices  at  the  rool  of  the 
neck  "r  on  the  upper  portion  of  the  chest.  The  chief  danger  of  the 
n  of  this  bone,  particularly  its  inner  half,  which  most  frequently 
requires  operation,  is  in  the  near  proximity  of  very  large  vessels,  which, 
if  injured,  would  destroy  the  patient.     Fortunately  for   the  operator, 


190        RESECTIONS    UPON     I  HI.    I   I'l'l'.lt    EXTREMITY 

nature  in  attempting  to  get  rid  of  the  old  diseased  bone,  has  usually 
i  hi  ed  i  around  the  clavicle  as  to  separate  th< 

portent  b  certain  distance,  whi  in  bo  more  readily 

avoided.     A.  now  deposit  of  bone  has  usually  taken  place  around  the 
necrosis,  and  it  i;1  only  oeoessary  to  cm  Into  this  involucrum  <n 
of  new  bone,  to  enable  one  tn  ron  the  diseased  portion. 

At  times,  however,  it  is  aeeessary  t"  remove  the  entire  thickness  of 
the  bone  for  one-half  of  it*  length  An  Inoision  is  made  parallel 
with  and  directly  upon  the  bone,  sufficiently  elongated  to  expose 
freely  the  diseased  portion  which  is  to  be  removed.  If  it  lie  the  sternal 
portion  of  the  bone,  great  care  must  be  used  in  detaching  the  gr< 
toral  muscle  below  and  the  sterno-cleido  mastoid  above  from  the  sur- 
face of  the  clavicle.  Using  the  back  or  handle  of  the  knife,  or  the 
point  of  a  grooved  director,  the  entire  circumference  of  the  bone  is 
isolated,  when  a  chain-saw  is  placed  around  tho  external  portion  to  be 
divided,  and  by  cutting  forward  the  shaft  is  severed.  Should  an  ordi- 
nary saw  bo  used,  the  flat  handle  of  a  scalpel  or  the  blade  of  a  small 
spatula  is  passed  under  the  clavicle,  which  pro  too  is  the  important  soft 
parts  beyond,  and  prevents  any  injury  from  the  saw.  When  the 
of  the  bone  is  divided,  the  cut  end  is  drawn  directly  forward  to 
rate  it,  as  fur  as  possible,  from  the  blood-vessels  al  the  rout  of  the  neeki 
By  grazing  the  posterior  face  of  the  b  >ne  with  the  edge  of  the  knife 
it  is  denuded  of  all  soft  tissue,  and  a  careful  section  of  the  liga- 
ments at  the  sterno-elavioular  junction  isolates  completely  the  b , 

As  the  internal-mammary,  subclavian,  and  transverse  cervical  arteries, 

with  ;n mpanying  veins,  and  also  the  upper  portion  of  tho  pleuraj 

with  apex  of  the  lung,   have  immediate   relations  with  tho  po 
border  of  the  claviole,  this  operation  will  not   be    undertaken  except 
by  those  familiar  with  the  a  tatomy  of  this  region,  and  fully  aw  i 
the  dangers  to  be  avoided.     With  similar  care  in  isolating    the  bond 
from  the  soft   parts,  the  outer  half  of  the  clavicle,  or  even   the  entire 
bone,  may  be  successfully  rcui"\  ■  1. 

■   HOH    oK    THE    SCAPULO   HUMERAL  ARTICULATION.— When 

tion  of  the  shoulder-joint  has  been  deemed  advisable,  one  of  two  meth- 
ods might  be  adopted  :  One  prooedurt nsiste  in  outting  up  an  anterior 

and  outer  flap  formed  of  the  deltoid  musole,  which  exposes  freely  the 
lead  of  the  bone,  and  facilitates  exoision,  The  other  mathod,  a  per- 
pendicular inoision  upon  the  anterior  fa f  the  joint,  exposes  the  head 

of  the  bone  with  more  difficulty ;  but  as  this  plan  does  not  out  up  the 
entire  attachment  of  the  deltoid,  it  has  its  advantages.  Plate  12,  ti.ur- 
1,  explains  the  method  of  reseoting  by  making  a  deltoid  flap.  The  arm 
being  drawn  upward  and  inward,  the  point  of  the  knife  enters  the  arm 
isterior  portion,  just  in  front  of  the  posterior  fold  of  the  arm- 


RESECTION    or   THE   SHOULDER-JOINT.  A{.)\ 

pit,  and  a  little  in  advance  <>f  the  point  of  perforation  for  Lisfrano's 

flap  amputation.  The  blade  glides  forward  over  the  head  of  the  hume- 
rus, opens  the  capsule,  and  perforates  the  skin  on  the  upper  and  anterior 
portion  of  the  arm,  immediately  below  the  accromial  process  of  the 
SCapala;  by  cutting  downward  and  outward  an  external  flap  is-made  of 
the  deltoid  muscle.  If  the  head  of  the  bone  has  not  been  altogether  de- 
tached from  the  shaft,  carrying  the  elbow  across  the  chest  and  rotating 
the  arm  will  force  the  head  against  the  outqr  portion  of  the  capsule, 
and  by  successive  strokes  of  the  knife,  cutting  through  the  capsular 
ligament  and  rotatory  muscles  attached  to  the  tubercles  of  the  hume- 
rus, the  head  will  be  turned  out  from  its  synovial  cavity.  As  the  elbow 
of  the  arm  upon  which  the  operation  is  being  performed  is  carried  up- 
ward over  the  chest,  the  head  of  the  humerus  projects  from  the  cavity, 
and  allows  the  kuife  to  graze  its  inner  surface  and  isolate  it  for  a  suffi- 
cient distance  from  all  soft  parts.  A  chain-saw  is  then  passed  around 
the  bono,  and  by  steady  traction  on  each  handle,  alternately,  the  neck 
or  shaft  of  the  humerus  is  smoothly  and  rapidly  divided.  When  an 
ordinary  saw  is  used,  the  flat  handle  of  a  scalpel  or  the  blade  of  a  spat- 
ula will  be  placed  behind  the  neck  of  the  bone,  to  protect  the  soft  parts 
while  the  saw  is  being  applied.  As  the  nervous  supply  of  the  deltoid, 
and  also  in  part  its  nutrition,  is  destroyed  by  this  flap  section,  atrophy 
and  paralysis  of  the  muscle  ensue.  It  was  on  account  of  this  sequela 
of  resection  by  a  deltoid  flap,  that  a  modification  of  the  operation  was 
suggested. 

Plate  12,  fig.  2,  represents  the  method  of  resecting  the  shoulder-joint 
by  a  perpendicular  incision  of  five  or  six  inches  iu  length  on  the  ante- 
rior surface  of  the  shoulder,  commencing  immediately  below  the  accro- 
mial process  and  extending  down  to  the  bone,  parallel  with  the  arm, 
cutting  through  the  middle  of  the  deltoid  muscle.  The  anterior  cir- 
cumflex artery,  supplying  the  deltoid  and  clasping  the  surgical  neck  of 
the  humerus,  is  divided  in  the  first  incision,  and  should  be  ligated.  A 
retractor  or  dilator  is  put  in  the  wound,  and  each  lip  of  the  incision 
drawn  forcibly  outward  so  as  to  expose,  as  much  as  possible,  the  deep- 
er parts.  If  tho  head  of  the  bone  has  beencrushod.  the  fragments  arc 
seized  with  a  heavy  dressing  or  tooth  forceps,  and  removed  by  isolat- 
ing them  from  their  muscular  connections.  As  the  head  of  the  hu- 
merus is  nourished  solely  by  the  vessels  running  through  the  shaft, 
the  severing  of  the  head  from  the  shaft  converts  it  into  a  foreign  body 
within  the  joint,  which  must  be  removed.  If  the  ball  has  traversed  the 
articulation,  perforating  without  severing  the  head,  the  length  of  tho 
arm  can  be  used  as  a  lever,  and,  by  rotating  the  head  within  its  capsule, 
the  rarloui  rotatory  muscles  attached  about  the  anatomical  neck  of  tho 
bone  are  brought  under  the  knifo.  These  are  cut  aorosi  aa  •  tpoaed,  the 
capsule  widely  opened    by  a  transverse   incision,  and  by  carrying    the 


492  [ON    <T   THE   SHOULDER- JOINT. 

elbow  backward,  pushing  it  nt  the  same  time  upward,  the  heail  of  the 
will  be  dislodged.  As  soon  as  Lhe  head  is  freed  the  knife  is  pass- 
ed behind  it.  and  the  neck  isolated  to  the  extent  of  the  pat- 
ula  is  placed  behind  it  to  protect  the  Boft  parts,  and  the  head  of  the 
bone  is  reran  b4> 

In  the  operation  by  a  horizontal  anterior  incision,  the  wound  is  usu- 
ally made  over  and  parallel  with  the  long  head  of  the  biceps  muscle, 
which  tendon  should  be  carefully  lifted  from  it?  lied  in  the  bicipital 

groove  and  drown  to  the  inner  side  of  the  wound.  It"  this  tendon  he  di- 
vided, it  impairs  the  usefulness  of  the  forearm  by  injuring  one  of  the 
principal  muscles  of  pronation.  By  the  anterior  horizontal  incision,  the 
large  posterior  circumflex  artery,  the  chief  source  of  nutrition  tor  the 
deltoid  muscle,  and  the  circumflex  ucrve,  which  also  supplies  it,  escape 
injury,  as  they  both  pass  under  the  humerus  and  supply  the  muscle 
from  its  posterior  portion. 

In  military  surgery, as  resection  is  most  frequently  performed  for  fract- 
ures of  the  head  and  upper  portion  of  the  shaft  extending  into  the  seap- 
ulo-humeral  joint,  the  resection  consists  usually  in  removing  all  spioulsa 
or  fragments  of  bone,  including  the  head,  and  in  sawing  off  the  BpioU- 
lated  extremity  of  the  shaft  smoothly.  ,\s  much  as  lire  inches  of  the 
shaft  and  head  have  been  removed,  leaving  a  useful  forearm  and  hand, 
and  often  somo  useful  movements  in  the  arm.  In  these  eases  in  which 
the  crushing  of  the  neck  has  isolated  the  head,  mueh  difficulty  will  be 
found  in  removing  this  portion  from  the  glenoid  cavity,  unless  the  pro- 
truding portion  be  seized  with  a  heavy  forceps  resembling  a  straight 
tooth  forceps,  by  the  assistance  of  which  the  head  can  be  rotated  and 
its  ligamentous  and  teiidiiioit.-  attachments  divided. 

It  the  resection  l"    performed  for  caries  or  necrosis,  the  lip   of  the 

glenoid  cavity  may   bave  become  involved  in  the  disease,  and.  the  •  1  i s - 

d  portions  must  be  removed  bj  a  gouge  or  cutting  bone-pliers.  W  Ion 

all  fragments  hai  e  been  renxn  ed  and  bleeding  \  esscls  ligated,  the  wound 

is  closed  by  a  BUfficienl  number  of  BUtUTOS,  having  a  small  portil  0  of 
the  wound  open  for  drainage.  A  large  portion  of  the  wound  will  unite 
by  the  fust  intention,  bul  a-  the  secretion  of  pus  from  the  cavity  is  usu- 
ally large  and  persists  for  some  linn',  the  opening  left  at  the  inferior 
portion  of  the  wound  discharges  freely  for  sometime.  If  the  entire 
wound  be  brought  in  apposition,  the  collection  of  pus  within  the  cavity 
having  no  mean-  of  esoape,  will. by  internal  pressure,  cause  agonizing 
pain,  until  it  breaks  through  the  skin,  fold  water  dressing  and  the 
of  diluted  pyroligneous  acid  to  oorreel  the  fostor  from  the  profuse  dis- 
charge,  prises  the  Local  treatment     After  the  operation  the  arm  is 

secured  firmly  to  the  trunk,  so  as  to  restriot  all  movements  in  it,  inas- 
much as  any  motion  in  the  cut  <  ictrt  mity  of  the  hone  produces  severe 
pain.     This  bandage  should  only  be  removed  when  it  becomes  loosened 


RESECTION    OF    THE    ELBOW-JOINT.  493 

or  much  soiled  with  pus,  and  when  renewed  the  arm  must  bo  held 
firmly  while  the  bandage  is  taken  off  and  reapplied.  Tho  general  treat- 
ment will  differ  in  no  respect  from  that  recommended  for  all  exten- 
sive .suppurating  wounds,  viz  :  opium  to  allay  pain,  and  good  strong 
food,  with  stimuli,  to  support  the  system. 

Resection  OF  the  elbow-JOINT  is  considered  a  preferable  operation 
to  amputation  of  the  arm,  as  it  is  less  fatal  in  its  results,  and  saves  a 
useful  extremity.  This  operation  la  applicable  in  military  surgery  to  all 
fractures  involving  the  joint,  the  portion  of  bone  removed  being  con- 
linod  to  that  injured.  It  must  be  remembered  that  the  elbow-joint  is 
composed  chiefly  ef  the  two  bones,  humerus  and  ulna,  the  radius  enter- 
ing  but-  little  into  the  formation  of  this  articulation.  When  the  arm  is 
extended  the  olecranon  process  of  the  ulna,  playing  around  the  trochlea 
of  the  humerus,  closes  in  the  back  of  the  joint.  The  bones  are  held  in 
apposition  by  strong  lateral  ligaments,  the  strength  of  the  articulation 
in  front  depending  upon  the  tendinous  fibres  of  the  biceps  and  coraco- 
brachial muscle,  while  the  attachment  of  the  triceps  muscle  to  the 
olecranon  process  of  the  ulna  protects  the  joint  from  the  back.  The  ar- 
teries which  course  over  the  posterior  surface  of  the  joint  are  all  small 
muscular  branches,  the  brachial  artery  lying  in  front  of  tho  arm.  A 
large  nerve,  the  ulna,  lies  upon  the  posterior  surface  of  the  internal 
condyle  of  the  humerus,  and  is  the  only  important  structure  liable  to 
injury. 

Two  methods  aro  recommended  for  resecting  this  joint.  In  one.  a 
straight  longitudinal  incision,  parallel  with  the  limb  and  five  inches  in 
length,  is  made  over  the  back  of  the  joint,  extending  directly  to  tho 
bono.  The  Lips  of  this  incision  arc  dissected  up  from  the  soft  parts,  cut- 
ting always  on  a  level  with  tho  bone.  By  so  doing  the  ulna  nerve  will 
bo  lifted,  with  the  soft  parts,  over  the  internal  condyle,  and  as  it  will 
not  be  exposed,  will  escape  injury.  When  the  lips  of  the  wound  can  bo 
sufficiently  drawn  apart  so  M  to  expose  the  entire  width  of  the  joint,  tho 
tendinous  attachments  of  tho  triceps  muscle  arc  cut  transversely,  the. 
postorior  ligament  divided,  and  t  lie  joint  largely  opened  by  cutting  off 
the  olecranon  process.  This  is  effected  by  applying  the  saw  to  its 
base  where  this  process  of  bone  meets  the  anterior  or  coranoid  \ 
Tho  lateral  ligaments  arc  now  cnl  through  with  the  point  of  the  knife, 
which,  in  connection  with  the  bending  of  the  joint,  liberates  all  of  the 
bones. 

If  the  injury  U  confined  to  the  lower  portion  of  the  humerus  alone, 
only   its  irregular,  broken  surface  is  removed   with   the  saw.   in    con- 
nection with   the    olecranon   process  of  the  ulna — the  Boft    par! 
protected  bythebladeof  a  spatula,  placed  between  tho  Lend  t>>  be  re- 
moved and  t:  hould  the  humeral  < 


104  BE   whim   roiK 

and  ulna  all  •]  ..r  fractured,  their  broken  oust   Im> 

i   with    tin-   saW|  mootb  cat  ends  upon  nil   the 

iculse  whii  h  resulted  from  tl 
tho  ball.     After  the  resection  and   liga'ion  of  bleeding  vessels,  the 
wound  is  closed  by  sutures.     The  arm,  secured  upon  an  anterior  angular 
splint,  long  enough  to  support  the  extremity  from  the  upper  third  ol  the 
humerus  to  the  fin  •  t  ;ii  ■  ri^lit  angle,  is  laid  upon  a  pillow. 

In  securing  this  splint  the  posterior  f ,] ' i"t>  of  the  elbow-joint  Is  nol 
.,.\cr'.l  by   the   b  thai    ii  remaini  i   inspection 

and  the  application  of  appropriate  dressing.  Ligamentous  union  in 
time  forms  between  the  ends  of  the  bono,  and  a  very  useful  limb  is 

:  >  cd. 

The  other  method  of  exposing  the  joint  from  its  posterior  surface,  is  by 
ninking  s  longitudinal  incision  on  the  onter  "r  inner  side  of  the  baek  Of 
the  arm,  which,  oommenchtg  three  inches  above  the  joint,  terminates 
opposite  t'i  the  base  of  the  olecranon  process.  The  inferior  termination 
of  the  inoision  is  me  I  by  a  trant  verse  inoision  extending  across  the  joint, 
L-sbaped.     [f  mort  space  is  n  quLn  d,  o  second  inoision  on  the  inner  ride 

of   the  arm,  and  parallel  with  the  first,  forms  a  i l-sbaped  flap,  whioh, 

when  dissected  op,  will  expose  sufficiently  the  Inferior  extremity  of  the 

humerus.      Should  the  heads  "I   the  radius  ami  ulna  lie  found  di 

the  perpendicular  incisions  can  be  prolonged,  H-like,  and  two  square  flaps 

ed  up — plate  12,  fig.  i.  In  making  the  in  tenia  I  inoision  oare  musl 

be  taken  not  to  injure  the  ulna  nerve,  whioh  must  be  sought  for  and 

drawn  to  the  outer  Bide  of  the  wound.     Although  the  combination  of 

litates  tl"  exposure  and  resection  of  the  articulating 

.   ill  the  bones,  yet  i'  leav<  s  a  muoh  Larger  wound  than  where  the 

median    incision  is    made;   nor  dees   the  soft  parts  Upon  liiel.aek 

of  the  aim  give  as  much  support  to  the  resected  joint.  In  securing  the 
limb  after  the  r<  section,  som<  prt  fers  straight  splint  on  theanteri 
tion  of  the  arm,  as  exeroising  less  tension  on  the  wound.  An  angular 
splint  is,  however,  found  the  most  convenient.  It  requires  many  months, 
aftei  cicatrization  is  completed,  heiuie  the  limh  regains  strongth  and 
use  ful  i 

I:  i  - 1  -  tion  or  Tin.  w  rib  i-.ioint  is  one  not  often  called  for  in  gunshot 
wounds,  and,  as  a  primary  operation,  gives  so  little  success  that  the  op- 
eration is  discouraged.  Asa  secondary  i  peration,  for  necrosis  of  either 
the  oarpeJ  extremity  of  the  radius  or  ulna,  good  results  are  obtained. 
The  diseased  bone  can  usually  *  by  a  horizontal  incision  over 

t  lie  joint  and  pa  nil  lei  with  the  bone  to  be  removed.  If  the  one  incision 
is  found  to  restrict  too  muoh  the  manipulation  of  the  surgeon,  its  inferior 
portion  may  he  extended  at  right  angles  across  the  joint.  When  the 
oarpal extremitiee  of  both  bon  md  require  i\m-  ■ 


RESECTION    OF   Tin;   INFERIOR   EXTREMITY.         495 

pcndicular  incisions  should  be  made  (plate  12,  fig.  6)  over  the  outer 
and  posterior  edge  of  each  bone.  The  tendons  of  su«h  muscles  as  lie 
in  the  way  are  carefully  drawn  to  one  side,  and  the  bone,  having  been 
isolated  of  soft  parts  by  careful  dissection,  is  divided  by  a  chain-saw, 
bone-pliers,  or  ordinary  saw.  As  the  main  vessels  lie  upon  the  anterior 
face  of  the  arm,  they  escape  division.  If  the  longitudinal  incisions  aro 
sufficiently  long,  the  ends  of  the  bones  can  bo  readily  removed.  Should 
more  room  be  required,  however,  a  transverse  incision  across  the  back 
of  the  wrist,  uniting  the  longitudinal  incisions,  will  permit  of  a  largo 
square  flap  of  skin  being  turned  up.  The  flap  should  be  but  skin-deep, 
inasmuch  as  the  tendons  on  the  back  of  the  wrist-joint  are  to  be  protect- 
ed. All  of  these  must  be  drawn  asido  and  not  divided;  otherwise,  the 
ubc  of  the  hand  and  fingers  will  be  destroyed.  The  closure  of  the 
wound,  securing  rest  and  quiet  to  the  hand  'and  forearm,  by  attaching 
it  to  a  broad  splint  placed  upon  its  anterior  surface  from  the  elbow  to 
beyond  the  fingers,  and  the  local  treatment,  are  similar  for  all  resections. 


RESECTIONS  OF  INFERIOR  EXTREMITY. 

Resections  of  the  lower  extremity  do  not.  give  such  flattering  results 
as  similar  operations  upon  the  upper;  yet,  when  we  take  into  consider- 
ation the  more  serious  operations  for  which  these  arc  offered,  we  must 
consider  their  adoption  as  a   material  advance  in  conservative  surgery. 
In  speaking  of  amputations  at  the  hip-joint,  wo  discouraged  the  ampu- 
tation as  one  nearly  invariably  fatal.     Resections,  on  the  contrary,  for 
gunshot  injury  to  thehead  of  the  femur,  where  the  bone  enclosed  by  the 
capsule  and  within  the  cotyloid  cavity  is  fractured,  with,  perhaps,  inju- 
ry to  the  acetabulum,  arc  sometimes  successful,  saving  a  useful  limb  as 
presenri  ng  the  life  of  the  wounded.    Some  surgeons  recommend 
that  this  resection  be  performed  always  as  a  secondary  operation — the 
a  of  a  successful  result  being  greater  than  when  the  operation  is 
performed  immediately  after  the  injury.     Two  methods  are  offered  for 
Dg  t/ir  hip-joint.  It  must  be  remembered  thai  the  bead  of  thi 
.ved  into  the  acetabulum,  where  it  is  held  firmly  by  tho  ligamen- 
tum  teres  and  thick  capsular  ligament)  surrounded  by  powerful  muscles. 
The  prominent  portion  of  the  femnr  on  the  outer  side  of  the  thi^h  is 
the  great    trochanter(  from  which   the  neek   and   head  of  the  bone  runs 
inward  and  upward,  more  or  less  obliquely.    The  gluteus  m&ximus  and 
muscles  run  o-,,r  and  are  attached  to  the  OBter  and   upper  side 
of  the  groat   trochanter.     The  ors  and   abductors,  including 

the  gluteus   minimus,  pyriformis,  gtmelli,  internal  obturator,  etc.,  aro 


IN    OE    niK    INFERIOB    EXTREMITY. 

■i  to  the  inner  face  of  the  trochanter,  and  into  the  fossa  at  its 
base.  No  reasons  or  nerves  of  importance  run  on  the  outer  Mile  of  the 
hip-joint.  The  large  arteries,  veins,  and  nerves  all  pass  on  the  inner 
and  anterior  side  of  the  joint,  ami  are  only  injured  from  carelessness 
in  manipulating. 

By  one  method,  a  straight  Incision  is  ma<le  upon  the  outer  side  of  the 
thigh,  six  inches  long,  and  parallel  with  the  limb  ;  a  short,  sharp- 
pointed  knife  is  thrust  into  the  upper  part  of  the  thigh,  on  a  level  with 
and  one  inch  behind  the  anterior  superior  spine  of  the  ilium.  Cutting 
directly  to  the  bono,  tho  Incision  is  extended  downward  over  the  tro. 
ohanter  sufficiently  long  not  to  embarrass  the  operator— plate  13,  fig.  1. 
The  thigh  being  now  forcibly  abducted  so  as  to  put  the  rotatory  and 
abductor  muscles  upon  the  stretch,  they  are  divided  by  the  point  of  tho 
knife,  and  the  capsule  largely  opened  from  the  outer  side  of  the  joint. 
By  rotating  the  thigh  a  much  larger  surface  of  the  capsule  is  brought 
under  the  knife,  which  facilitates  tho  oscapo  of  the  head  of  the  hone. 
Tho  ligumentum  teres  is  now  divided  ;  tho  soft  pans  in  front  of  the 
neck  carefully  divided  s6  as  to  avoid  important  vessels,  a  chain -saw 
passed  around  the  neck  to  bo  removed,  and,  by  steady,  alternal 
tion  upon  the  handles,  the  afieeted  portion  of  the  bono  is  sawed  through. 
When  a  chain-saw  is  not  at  hand,  the  Boft parts  are  protected  by  means 
of  a  slip  of  wood  or  a  spatula,  and  an  ordinary  saw  applied.  In  com- 
pound fractures  from  gunshot  wounds,  all  of  the  crushed  portion  of  tho 
bone  must  bo  removed,  if  it  involves  as  much  as  even  three  or  four 
inches  of  tho  neck  and  shaft.  Should  the  acetabulum  bo  also  d 
or  fractured,  all  the  affected  portion  must  bo  removed — a  gouge  or  bouo 

aged.      After  the  completion  of  tho  resection  and  : 
of  tin-  bleedin  ;  vei  sols   the  wound  is  olosed  by  sutures,  leaving  its   in- 
ferior   portion   open    lor   the  escape   of    all  from   the  cavity. 
Alter   the   operation,   the  I, ml,   i-  seoured   upon  a  straight,  long   Splint  J 

although  many  surgeons  prefer  that  the  limb  be  brouj  hi  into  a  straight 

position,  and  lie  upon  tho  bed  or  cushions,  without  being  trammelled 
by  splints  or  bandagt  of  any  kind.  The  progress  of  the  ease  is  mofe 
or  less  slow.  Suppuration  from  the  wound  is  at  first  prof uso,  and  un- 
cus has  a  free  vent,  infiltration  may  take  place.  By  degrees 
tlii;   discharge  diminishes,  the  wound  heals,  the  patient  is  allowed  to 

use  crutches,  and,  finally,  may  possess    JO  .-Iron-  a  limb  that,  with  the 
use  of  a  high-heel  boot  and  a  stick,  he  can  walk  very  satisfactorily. 

An  objection  having  been  made  by  some  operators  to  tho  difficulty  of 
exposing  and  liberating  the  head  of  the  femur  from  its  cavity  by  the 
straight  inoision,  they  have  suggested  many  methods  by  which  thi? 
tedious  step  of  the  operation  could  fie  facilitated.  A  convex  flap,  cut 
upward  by  transfixion,  the  base  resting  upon  the  outer  portion  of  the 
thigh  .nifit  below  the  great  trochanter,  is  ooneidered  "iit>  of  the  most 


RESECTION    OP   THE    KNEE-JOINT.  497 

desirable.  This  flap  can  be  formed  by  cutting  around  the  margin 
of  the  groat  trochanter  horsoshoe-like,  the  convex  portion  of  tho  flap 
extending  two  inches  above  the  trochanter.  If  tho  knife  bo  passed 
down  deep  enough,  this  wound  would  expose  the  head  of  tho  femur. 
In  milking  a  transfixion,  a  narrow,  sharp-pointed  knife  may  bo  thrust 
through  the  outer  portion  of  the  thigh  on  a  level  with  the  uppor  part 
of  the  trochanter,  the  point  of  the  kuife  passing  from  behind  forward, 
under  the  gluteus  medius  muscle,  and  through  the  trochanteric  fossa, 
between  the  great  trochanter  and  the  neck.  When  the  knife  has  trans- 
fixed the  outor  portion  of  the  limb  a  flap  is  made  upward,  which  will, 
in  cutting  out,  sever  all  the  rotatory  and  abductor  tendons  attached 
to  the  great  trochanter.  By  carrying  the  thigh  across  tho  sound  one 
and  rotating  the  knee  forcibly  inward,  the  capsule  can  be  largely  di- 
vided, the  head  of  the  bono  turned  out  of  its  cavity  (plate  13,  fig.  2), 
and  the  saw  applied.  Or,  the  neck  of  the  femur  can  bo  isolated  and 
divided  by  a  chain-saw  passed  around  it,  or  by  the  ordinary  saw,  be- 
fore the  head  is  turned  out  of  the  acetabulum.  The  neck  can  then  be 
seized  with  a  strong,  straight  tooth  forceps,  and  rotated  so  that  tho 
capsule  and  contiguous  muscles  can  be  easily  divided.  Should  the  neck 
of  the  femur  have  been  fractured,  the  part  protruding  from  the  ace- 
tabulum is  firmly  seized  by  a  strong  forceps  and  rotated  during  the 
division  of  the  ligaments.  This  flap  incision  is  preferred  by  some 
surgeons,  as  it  offers  a  ready  escape  for  those  secretions  which  will 
form  freely  in  the  wound.  Any  diseased  portion  of  the  acetabulum 
must  be  removed  by  the  gouge. 

Resbction  of  the  knee-joint. — This  joint  is  formed  by  the  ex- 
panded extremity  of  the  femur  above  and  the  tibia  below,  the  anterior 
face  of  the  articulation  being  closed  in  by  tho  patella.  The  lateral 
and  crucial  ligaments  keep  tho  bones  in  apposition,  and  give  strength 
to  the  joint.  All  important  vessels  and  nerves  pass  behind  the  joint 
through  the  popliteal  space.  In  resecting  this  joint  for  perforating 
wounds  followed  by  suppurative  synovitis,  or  in  cases  of  compound 
fracture  involving  the  heads  of  tho  bones  entering  into  the  formation 
of  the  articulation,  the  patient  is  put  under  the  influence  of  chloro- 
form, which  is  now  in  universal  use  whenever  operations  of  any  kind 
are  to  be  performed.  With  the  leg  flexed  upon  the  thigh,  tho  surgeon 
makes  a  convex  incision  extending  across  the  entire  anterior  portion  of 
the  joint  from  one  condyle  of  the  femur  to  the  other,  encircling  the 
upper  border  of  the  patella.  Another  curved  incision  of  similar  dimen- 
sions passes  below  the  patella,  which  encloses  this  bono  between  two 
elliptical  Incisions.  These  incisions  are  contiuued  through  the  entire 
thickness  of  the  sofl  parts,  and  the  patella  isolated  and  removed.  This 
exposes  the  entire  anterior  portion  of  the  knee-joint,  and  by  cuttiDg 


498  RESECTION    OF   THE    ANKLE-JOINT. 

across  the  crucial  ligaments  in  the  centre  of  the  articulation,  between 
t he  cupped  cavities  of  the  tibia  and  condyle  of  the  femur,  and  also 
dividing  the  internal  and  external  ligaments,  the  joint  is  widely  opened, 
and  either  the  extremity  of  the  femur  or  tibia  can  be  turned  out  of  the 
wound  and  resected.  Either  or  both  bones,  if  diseased  or  injured, 
are  resected.  They  are  isolated  from  the  soft  parts  posteriorly  as 
well  as  anteriorly ;  a  guard  is  placed  behind  the  bono  for  the  protec- 
tion of  the  soft  parts  and  important  vessel*  (plate  IS,  fig.  3),  while  the 
affected  portion  of  the  head  and  shaft  is  sawed.  In  this  resection  it  is 
considered  advisable  to  remove  as  much  of  the  Bynovial  surface  a-  pos- 
sible, and  when  it  is  not  necessary  to  resect  the  tibia,  the  semilunar 
cartilages,  with  their  free  synovial  surfaces,  lying  upon  the  upper  sur- 
face of  the  bone,  to  deepen  the  cups  for  the  better  reception  of  the  con- 
dyles of  the  femur,  should  be  removed.  When  it  is  remembered  that 
the  degree  of  deformity  and  shortening  of  the  limb  will  depend  upon 
the  extent  of  the  bone  resected,  only  the  crushed  portion  in  injury,  or 
the  ulcerated  surface  in  disease,  should  be  removed.  When  a  Bection 
of  either  or  both  bones  is  required,  the  saw  should  be  so  applied  that 
the  cut  surface  will  be  brought  in  uniform  apposition  to  "the  opposing 
bone.  After  the  section  of  the  bones  the  soft  parts  are  adjusted  by 
points  of  suture,  and  the  usual  water  dressing  instituted.  As  rest  and 
quiet  in  the  limb  are  essential  to  a  successful  issue,  a  straight,  broad, 
splint  is  secured  to  the  back  of  the  log,  reaching  from  the  buttock  to 
the  heel,  and  is  retained  until  consolidation  of  the  joint  is  effected.  It 
is  expected,  in  the  successful  cases,  that  the  joint  remain  permanently 
stiffened  by  fusion  of  tho  tibia  and  femur. 

Resection  of  the  ankle-joint,  like  that  of  the  wrist,  is  an  opera- 
tion sometimes  required  for  gunshot  injuries  to  the  bones  forming  this 
articulation.  Straight  incisions  on  tho  lateral  surface  of  the  leg,  par- 
allel with  the  tibia  or  fibula,  and  extending  to  the  inferior  border  of 
the  malleoli,  will  give  ample  space  for  isolating  tho  diseased  or  fractur- 
ed extremity  of  either  of  these  bones.  Should  more  space  be  needed 
the  inferior  end  of  the  incision  may  be  extended  at  right  angles  across 
the  anterior  surface  of  the  bone.  These  soft  parts  being  protected  by 
a  guard,  a  saw  or  chisel,  as  in  plate  13,  fig.  4,  will  divide  the  bone,  when 
the  lower  fragment  should  be  seized  by  a  strong,  straight  tooth  forceps, 
and  while  rotating  it,  the  ligaments  holdiug  it  to  the  tarsal  bones  can 
be  severed. 


LIGATION    OJT    ARTERIES.  4(J9 


LIGATION  OF  ARTERIES. 

Arteries,  as  they  oourse  through  limbs,  seldom  perforate  muscles,  but 
usually  lie  in  the  intermuscular  spaces,  accompanied  by  veins  and  nerves 
— the  veins  and  arteries  being  enveloped  in  a  layer  of  condensed  cellu- 
lar tissue,  called  the  sheath  of  the  vessels.  All  arteries  of  the  largest 
size,  such  as  the  carotid,  subclavian,  and  femoral,  have  but  one  vein  ac- 
companying them,  which  is  always  larger  than  the  artery,  and  usually 
lies  upon  tho  inner  or  most  protected  side  of  the  vessel.  Arteries  of 
the  second  class,  as  brachial,  radial,  ulnar,  and  tibial,  are  accompanied 
by  two  veins,  one  lying  on  cither  side  of  the  vessel.  A  large  nerve  or- 
dinarily accompanies  the  artery;  more  especially  those  of  the  second 
and  third  magnitude.  It  usually  courses  upon  the  outer  or  more  ex- 
posed  .<ide  of  the  artery,  and  without  the  sheath  of  the  vessels  ;  so  that, 
in  cutting  down  to  expose  an  artery,  when  the  immediate  vicinity  of 
the  vessel  is  reached,  the  nerve  is  first  found  upon  the  outer  side  of  tho 
sheath,  and  this,  as  an  important  landmark,  determines  whero  the  arte- 
ry should  be  sought.  The  superficial  landmarks  are  the  muscles  be- 
tween which  the  arteries  lie;  also  the  direction  of  the  vessels  in  relation 
to  bony  prominences;  and  their  pulsation. 

In  the  ligation  of  arteries,  the  rule  is  to  make  an  incision  parallel 
with  their  course,  as  one  least  likely  to  injure  the  vossel  sought  for. 
When,  however,  the  position  of  the  artery  is  doubtful  from  tho  obscuri- 
ty of  the  landmarks,  which  is  the  case  with  one  or  two  very  deeply-seat- 
ed vessels,  viz  :  the  glutial — it  is  preferable  to  make  the  incision 
across  the  course  of  the  artery. 

The  exact  position  and  direction  of  the  artery  having  beeu  determin- 
ed, the  skin  of  the  limb  where  the  incision  is  to  bo  made  is  rendered 
tense  by  the  surgeon,  either  by  stretching  it  between  the  thumb  and  in- 
dex finger  of  his  left  hand,  or  by  putting  the  four  fingers  of  his  left 
hand  iu  a  straight  line  over  the  course  of  the  vessel  and  making  a 
straight  incision  of  sufficient  length,  immediately  in  front  of  his  finger- 
nails. If  the  artery  be  deep-seated,  the  incision  should  extend  through 
skin,  cellular  tissue,  and  fascia,  directly  to  the  muscles.  As  most  arte- 
ries are  comparatively  superficial,  this  incision  should  not  extend  deep- 
er than  the  skin.  The  proper  form  of  knife  for  making  the  incision  is 
a  Bharp-pointed,  straight  bistoury  :  and  to  make  a  clean,  neat  wound, 
the  point  of  the  knife  should  pass  perpendicularly  through  the  thick- 
ness of  ihe  sljin,  then  depress  the  blade,  making  the  length  of  incision 
necessary,  and  again  elevate  the  blade  perpendicularly  before  the  inci- 
sion is  terminated,  so  that  the  skin  is  perfectly  divided  throughout  its 

entire  extent,  t lie  incision  Dot  ending  in  Bcratohei  OpoO  the  surface.      The 
superficial  layers  of  cellular  tissue  may  now  be  carefully  divided  by  the 


500 


l-IOATION    ol     AKT1 


point  of  (he  knife,  or  the  tissue  may  be  drawn  upward  by  seizing  il  with 
:.e  of  the  angles  of  the  wound.  Make  a  hole  in 
ii  by  outting  horizontally,  insert  the  point  of  a  grooved  director  in  this 
opening,  slide  the  instrument  under  the  cellular  tissue  for  the  entire 
length  of  the  wound,  and  holding  the  knife  with  the  i  dgi  turned  up- 
ward, run  ii.-  point  through  the  entire  length  of  the  groove,  which  will 
divide  oompletely  the  layer  of  tissue.  With  the  point  <>f  the  gi 
lireotor  the  cellular  tissue  around  U  tore  up,  which  i 

the  sheath  of  the  artery.     As  this  is  usually  a  Umgh  lay  <  r  of  membrane, 

iting  i"  be  torn,  it  is  ought  np  with  the  foroepi  as  before,  an 

opening  made  horizontally  in  it,   and  by  inserting  the  grooved  d 
through  this  orifice  the  sheath  can  be  divided  opwu  he  cel- 

lular ti 

Arteries  are  not    nourished  by  the   blood    which    runs  through  them, 
but  by  a   distinct  set  of  vessels  called  \  small 

size,  which  ramify  in  the  outer  coat  of  arteries,  and  which  are  furnish- 
ed from  tlmse  small  branch,  s  which  pass  in  from  the  sheath  of  the 
This  sheath,  from  which  these  small  vessels  aro  supplied, 
must  not  !"•  torn  up  to  too  great  an  extent,  or  the  artery  requiring  a 
ligature  is  Isolated  too  extensively  from  it-  oellular  envelopes,  and  the 
destruction  of  these  nutrient  vessel-  may  cause  sloughing  of  the  ar- 
tery and  secondary  hemorrhage.  A-  a  rule,  only  a  sufficient  i] 
made  between  the  sheath    and   the    artery    to   allow    the  passage    of  the 

in  needle  armed  with  the  ligature.    The  point  of  the  aneurism 
i-  always,  entered  between  the  vein  and  the  artery,  so  as  to  avoid 

injuring  the  thin  and  delicate  structure  of  the  vein  :  and  a<  the  vein  is 
usually  placed  upon  the  inner  side  of  the  artery,  the  needle  is  always 
Inserted  from  within  outward.  When  the  thread  is  passed  under  what 
we  suppose  to  be  the  artery,  it  should  be  drawn  upon,  so  as  to  raise  the 
vessel  and  obliterate  it-  calibre,  while  the  index  anger  of  the  - 
is  thrust    Into  the  wound    to  determine  whether  the  vessel  still  pulsates 

below  the  thread.     If  the  pulsation  Is  confined  to  thai  p  rti"n  above 

the  ligature  only  when  the  thread  is  drawn  upward,  with  DO  pulsation 
below  it,  while  this  latter  pulsation  i.-  resumed  as  soon  as  the  traelion 
Upon  the  artery   is  released,  we  may  feel  assured   that   the  propel 

i  secured.    This  preoautl y, inasmuoh as  veins  and 

nerves,  instead  of  arteries,  ha\  <    I.e.  Q  tied    by  operators  of    sonic  expe- 

rienoe  who  aegleoted  to  make  use  of  this  expedient 
Having  passed  the  ligature  under  the  artery     and  any  strong  thread, 

whether  <d"  cotton,  tlas.  or  silk,  will  answer.  QaZ    being  the    most  com- 
monly used — the  thread  is  tied  in  a  single  loop,  and  drawn  firmly  upon 
-el.  with  the  intention  of  cutting  through  the  two  inner  cats  of 

the  artery,  as  it  is  by  the  puokeringin  and  final  union  of  these  ooats  that 
the  artery  is  to   be  obliterated — plate  14,  tig's  1,  2,  8.     As  the  outer  or 


LIGATION    OF   ARTERIES.  501 

cellular  coat  is  very  tough  and  resisting,  there  is  no  fear  of  tearing  this 
through,  provided  the  fingers  are  placed  in  the  depth  of  the  wound  bo- 
fore  the  traction  upon  the  thread  is  made.  The  vessel  should  not  bo 
lifted  from  its  bed  during  (be  ligation.  The  thread  having  been  well 
waxed,  after  making  one  twist  upon  it  to  form  the  first  noose,  the  ends 
of  the  ligature  are  wrapped  around  the  little  fingers  of  both  hands  until 
the  thread  is  made  so  short  that,  when  the  index  fingers  of  both  hands 
are  thrust  into  the  depth  of  the  wound,  with  the  back  of  the  fingers 
placed  against  each  other,  using  the  knuckles  as  a  fulcrum,  the  extremi- 
ties of  the  fingers  are  forced  outward,  and  as  the  thread  is  drawn  tight- 
ly over  them,  the  noose  will  be  firmly  tied.  The  wax  prevents  the  thread 
from  Blipping  and  relaxing  its  firm  pressure  upon  the  vessel.  When 
the  operator  feels  that  he  has  exorcised  sufficient  traction  to  obliterate 
the  tube  and  sever  the  inner  coats,  he  draws  a  second  noose,  which  knots 
firmly  the  thread.  In  tying  arteries,  an  ordinary  knot  suffices,  provided 
the  ligature  has  been  well  waxed:  there  is  no  necessity  for  twisting  the 
ends  of  the  thread  twice,  as  formerly  recommended  by  surgeons — "the 
surgeon's  knot."  One  end  of  the  thread  is  cut  off  close  to  the  knot  ; 
the  other  is  brought  out  of  the  wound  and  secured  on  the  outer  side  of 
the  limb  by  a  piece  of  adhesive  plaster.  The  wound  is  then  closed  by 
a  sufficient  number  of  sutures.  If  nicely  brought  together,  the  lips 
usually  unite  by  the  first  intention,  leaving  but  a  small  fistulous  passage 
for  the  thread. 

From  the  eighth  to  the  sixteenth  day,  depending  upon  the  size  of  thfl 
artery  ligated,  the  degree  of  force  used  in  cutting  through  the  inner 
coats  and  compressing  the  outer,  and  the  more  or  less  perfect  isolation 
of  the  vessel,  the  thread  comes  away,  having,  by  its  pressure,  killed 
and  softened,  and  caused  to  slough,  in  the  line  of  pressure  only,  the  coat 
of  the  artery  encircled  by  the  noose  of  the  thread.  This  liniary 
(toughing  i.^  essential  to  the  escape  of  the  ligature.  It  is  only  when 
the  sloughing  is  more  extensive,  so  as  to  involve  the  inner  coats  which 
have  recoiled  away  from  the  thread,  that  secondary  heinorrli 
sues — plate  14,  fig.  3.  When  the  ligature  remains  on  longer  than  the 
period  above  stated,  slight  traction  may  be  daily  made  upon  it,  which 
will  hasten  its  escape  by  increasing  the  irritation  and  ulceration  in  the 
line  of  ligation.  The  retention  of  the  thread  U  often  due  to  the  want 
of  sufficient  traction  upon  the  thread  in  tying  the  artery — not  sufficient 
to  cause  the  thread  to  cut  through  the  inner  coats  and  strangulate  the 
outer  one — or  it  may  be  oaused  by  some  of  the  neighboring  tissue  being 
included   with  the  artery  in  the  noose.     The  only  plan    for  it.-^ 

moral,  where  it  remains  for  a  more  or  lees  protracted  period  in  the 
wound,  is  to  wait  patiently  upon  it.  making  moderate  traction  upon  the 
thread  daily.     Sometimes  the  wound  heals  up,  hugging  the  thi 

that   ii  re  |uirei  moderate  traction  to  draw  the  kn  't  through  the 


502 


LIGATION    OF    ARTERIE8. 


fistulous  passage  left  for  thread.     Unless  this  moderate  force  was  used, 
the  ligature  would  be  thought  still  connected  with  the  artery. 


LIGATION  OF  ARTERIES    OP  Till:  SI  PERIOR  EXTREMITY. 

Coneolidated  Tublr  ,,f  Ligation   of  Art- run,  made  up  fro* 
Surge*  "*    Office,  from  June  1,  1862,  t<i  February  1,  18 

,  //.  /:</■   . 


0 

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Remarks. 

Primary. 
Secondary. 

1 

5 

is 

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■4 

If. 
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17 
is 
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Average  period  at  which  hem- 
oi  i  hage  sel  In,  foi  which  ar- 

days. 

a 

In  li^atinp;  :irteries  in  their  course,  as  the  surgeon  can  most  frequent  - 
lj'  select  the  point  at  which  the  vessel  is  to  be  tied,  he  Bhould  always 
the  operation  upon  the  artery  as  far  as  possible  from  Large 
bran ob os.  Immediately  after  the  ligation,  a  clot  of  blood  forma  within 
the  upper  i >< > r t i< >n  of  the  vessel,  between  the  ligature  and  the  fn>t  col- 
lateral branch  given  off  from  the  artery.  This  clot  prevents  the  weak 
portion  of  the  vessel,  whore  its  Coats  had  been  cut  through  by  the  liga- 
ture, being  disturbed  during  the  cicatrization  or  union  of  these  ooats. 
Should  the  ligature  have  been  applied  in  the  vicinity  of  a  large  branch, 
the  lymph  thrown  out  by  the  •■  ■  ra  to  close  up  the  puckered  end 

of  the  tube  is  washed  away  by   the   current  of  blood;  no   clot  forms, 

and  - ndary  hemorrhage    will  probably   occur  when    the  ligature  es- 

i  rmii  the  vessel. 

To  ligate  arteries  in  their  course  certain  locations  are  [.referred,  and 
these  regions  must  be  carefully  studied,  so  that  all  the  relations  of  the 
arteries  bo  clearly  understood.  In  the  upper  extremity,  the  points  of 
•  Ii  ction  for  lighting  the  arteries  are  in  the  lower  third  of  the  axilla  for 
the  axillary  artery,  the  middle  uf  the  arm  for  the  brachial)  and  near  the 


LIGATION    OF    ULNA    ARTERY.  503 

wrist  for  the  radial  and  ulna,  although  sometimes  it  is  necessary  to  li- 
gate  either  of  these  in  the  middle  of  the  forearm,  or  to  secure  them  after 
they  have  passed  into  the  hand. 

After  the  subclavian  artery  has  passed  under  the  clavicle,  it  is  called 
axillary  artery.  It  then  continues  through  the  armpit  and  upon  the 
inner  side  of  the  arm  as  brachial  vessel,  until  it  roaches  the  anterior  pur- 
face  of  the  bend  of  the  elbow;  here  it  bifurcates  into  two  vessels,  the 
radial  and  ulna  arteries,  running  parallel  with  their  respective  bones. 
When  approaching  the  wrist  the  ulna  vessel  passes  under  the  annular 
iit  on  tin  inner  side  of  the  pisiform  bone,  and,  afler  a  perpendicu- 
lar course  of  one  and  a  half  inches,  forms  an  irregular  curve  in  the  palm, 
called  the  superficial  arch,  from  the  convexity  of  which  (plate  15,  fig.  3) 
branches  arc  given  off  to  supply  the  fingers,  while  the  continuation  of 
the  vessel  turns  upward  to  meet  a  branch  from  the  radial  artery,  and 
thus  completes  the  palmar  arch.  . 

Should  an  injury  to  the  inner  portion  of  the  palm  cause  annoying  and 
persistent  hemorrhage,  the  ulna  artery  can  be  secured  by  making  an  in- 
cision an  inch  in  length  on  the  inner  side  of  the  pisiform  bone,  cutting 
through  skin,  cellular  tissue,  o.ud  annular  ligament,  when  the  artery, 
lined  by  two  veins,  will  be  found  lying  upon  the  tendons  passing  over 
the  anterior  surface  of  the  wrist-joint,  and  having  the  ulna  nerve  upon 
its  outer  or  pisiform  border.  It  should  be  carefully  isolated  from  its 
accompanying  veins,  and  secured.  As  the  ligation  at  this  point  has  no 
special  advantage,  it  is  much  preferable  to  secure  the  artery  above  the 
wrist,  where  the  pulse  is  usually  felt.  In  this  region  the  pulsation  of 
the  artery  is  so  easily  found  that  there  can  be  no  difficulty  in  determin- 
ing its  position.  From  the  middle  of  the  bend  of  the  elbow  (plate  15, 
fig.  3)  the  ulna  artery,  g,  k,  accompanied  by  two  veins,  takes  a  curved 
course.  It  is  deeply  buried  in  the  arm,  lying  upon  the  deep  flexors,  and 
covered  by  the  superficial  layer  of  flexors.  After  traversing  one-third 
the  length  of  the  arm  in  this  obliquely  curved  course,  it  changes  its  di- 
rect ion  to  run  in  a  straight  course  downward  and  parallel  with  the  ulna. 
For  the  inferior  two-thirds  of  its  length  it  lies  upon  the  deep  flexor-  .f 
the  fingers,  between  tho  flexor  carpi  ulnaris  tendon,  f,  on  its  outer  or 
more  exposed  side,  and  the  flexor  sublimis  digitorum,  j,  on  its  inner 
side.  The  ulna  nerve  lies  upon  the  outer  side  of  the  vessel,  partly  cov- 
ered by  the  tendon  of  the  flexor  carpi  ulnaris  muscle.  When  the  arm 
is  so  swollen  or  fat  that  these  muscular  tendons  can  not  be  felt  under 
the  skin,  nor  the  pulsation  of  the  artery  perceived,  a  simple  rule  for  find- 
ing the  vessel  in  the  inferior  half  of  the  forearm  Would  be  to  ilraw  a  line 
from  the  epitrocbleea  to  the  inner  face  of  the  pisiform  bone.  Under 
this  line  the  artery  will  be  found.  An  incision  from  one  and  a  half  to 
two  inehes  in  length  is  made  in  this  line,  pasnng  through  the  skin 
and  cellular  tissue.     The  fascia,  which  i-  now  exposed,  U  pinched  op  at 


LIGATION    01    HAI'IAI,    ARTERY. 

one  end  of  the  wound)  and  a  small  orifice  is  made  into  it  fur  the  passage 
of  the  grooved  director,  upon  which  the  fascia  is  divided.     The  tendon 
of  the  flexor  carpi  ulnaris   is  then   drawn  outward,  and  the   :irt • 
found  lined  by   it-    .  baring   the   ulna  nerve   upon   its  outer 

border. 

When  it  becomes  neOOISfcry  to  li.'ate  the  ulna  artery  in  its  upper  half, 
as  its  pulsation  OU  not  he  felt,  the  course  of  the  vcs.-el  can  always  be 
determined  l>y  drawing  a  line  from  a  point  midway  between  the  con- 
dyles of  the  humeral  .1  of  the  elbow,  to  ■  point  on  tho  inner 
side  of  the  forearm  where  the  middle  third  joint  the  upper  third  of  the 
ulnu.  It  is  at  this  point  that  the  artery  hi  usually  sought.  It  can  bo 
found  nearer  the  elbow  joint,  but  ai  the  artery  is  very  deeply  seated,  and 
at  its  exposure  requires  the  division  of  the  superficial  flexors,  it  Is  con- 
sidered preferable  to  li^ate  the  humeral  artery  on  the  inner  side  of  the 

bioept  muscle.  Where  the  middle  and  upper  third  of  the  inner  border 
of  the  forearm  meet,  the  artery,  lined  by  its  veins,  has  already  escaped 
from  beneath  the  flexor  sublimis  digitorum,  and  can  he  found  in  the  in- 
termuscular space  between  the  flexor  sublimis  and  flexor  carpi  alnaris. 
An  incision  three  inches  Long  is  made,  aa  in  plate  L5,  fig.  I.     Bj 

live  layers  the  skin,  cellular  tissue,  uiid  superficial  fas  oil  are  divided. 
A-  the  artery  is  deeply  seated,  these  tissues  can  be  divided  without  cut- 
ting upon  a  grooved   dlreotor.     By  planing   the   index  finger  In  tho 

WOUnd  upon  the  inner  la f  the  ulna,  and   drawing   it.  with  pressure, 

toward  the  interior  oi*  the  arm.  the  finger  will  mount  over  the  belly  of 
the  Bezor  ulnaris  muscle,  and  suddenly  sink  into  a  depression,  which 
marks  the  intermuscular  space  between  this  muscle  and  the  flexor  sub- 
limis. With  the  point  oi"  the  grooved  director  held  firmly,  the  cellular 
-ue  of  this  intermuscular  space  is  torn  up,  the  inner  border  of  the 

flexor  alnaris  is  drawn  aside,  and  the  artery  is  found  beneath  it. 

The  radial  art*  ry  runs  a  rnuoh  straighter  course.  Prom  the  centre  of 
the  bend  of  the  elbow  il  follows  nearly  a  straight  course  downward, 
parallel  with  the  radius,  lying  in  an  intermuscular  space,  having  (pints 
16,  fig's  8,  9)  the  supinator  longus  muscle  on  its  outer  side,  and  on  its  in- 
ner side  the  pronator  radii  teres  for  its  upper  third,  and  theflexor  carpi 
radlalis,  »,  for  the  lower  two-thirds  of  its  course.      In  the  upper  half  of 

the  arm  the  artery,  '/',  lined  by  its  two  veins,  randy-,  is  deeply  seated, 
.  aa  it  lies  in  an  intermuscular  space,  its  pulsation  oan  be  felt     In 

the  lower   half  of  its  ir-e    it     i-  -  •  inperfioial  that   at     the  wrist   it   is 

only  SUbOUtaneOUS.  In  ligating  this  artery,  an  incision  made  in  any 
portion  of  the  arm  parallel  with  and  over  the  inner  holder  of  the  supi- 
nator longus  muscle,  will  alwaj  the  vessel.    Tho 

pulsation  of  the  artery  is  another  guide  j  and  a  third,  useful  at  all  times, 

Is  to  draw  a  line  from  the  middle  of  the  lend  of  the  elbow  to  the  inner 
surface  of  the  styloid  ■■  the  rudius.     An  incision  in  this  line, 


LIGATION    OF   BRACHIAL   ARTERY.  505 

one  and  a  half  inches  in  length  if  the  operation  is  performed  in  the  vicin- 
ity of  the  wrist,  or  from  two  and  a  half  to  three  inches  if  in  the  upper 
portion  of  the  forearm  (plate  15,  fig.  4),  extending  through  the  skin 
and  superficial  fascia,  will  always  expose  the  artery,  with  its  veins.  In 
the  uppor  portion  of  the  arm  the  artery  is  covered  by  the  inner  border 
of  the  spinator  longus  muscle,  which  overhangs  it,  and  must,  there- 
fore, be  drawn  aside  in  the  search. 

From  the  insertion  of  the  great  pectoral  to  the  bicipital  ridge  of  the 
humerus,  to  the  bend  of  the  elbow,  the  main  artery  of  the  arm  is  called 
brachial  or  humeral — plate  16,  tig.  11,  A.  It  lies  on  the  inner  side  of 
the  biceps  muscle,  D,  and  corico-brachialis,  C,  lying  upon  the  triceps 
and  brachialis  anticus,  and  surrounded  by  a  number  of  largo  veins  and 
nerves,  all  being  enveloped  in  a  loose  cellular  tissue.  The  median  nerve, 
G,  which  is  found  in  the  upper  portion  of  the  arm,  botween  it  and  the 
coraco-bracbialis  muscle,  crosses  the  course  of  the  artery  in  the  middle 
of  the  arm,  usually  in  front,  sometimes  behind  the  vessel,  and  is  found 
upon  its  inner  Bide  at  the  bend  of  the  elbow.  F,  the  brachial  vein, 
with  b,  the  basilic  vein,  accompany  the  artery.  A',  the  ulna  nerve, 
which  lies  in  juxtaposition  with  the  inner  surface  of  the  artery  in  the 
upper  portion  of  the  arm,  runs  obliquely  from  it  in  its  descent.  The 
artery  gives  off  but  two  large  branches  in  its  omirM.  the  superiorand  in- 
ferior profunda  branches,  both  from  the  upper  half  of  the  vessel.  If 
the  arm  is  not  very  stout,  the  pulsation  of  the  artery  can  bo  felt  upon 
the  inner  border  of  the  biceps  muscle  throughout  its  entire  extent. 
When  the  arm  is  extended  the  median  nerve  lifts  the  skin,  forming  a 
prominent  cord,  which  mark*  out  the  position  of  the  vessel,  and  cau  bo 
used  as  the  guide  to  the  artery.  The  inner  border  of  the  coraco-brachia- 
lis  and  biceps  muscles  are  the  satellites  of  the  artery.  In  ligating  the 
brachial  artery,  an  incision  from  two  to  three  inches  in  length,  is  made 
upon  the  inner  border  of  these  muscles  (plate  10,  fig.  2),  cutting  through 
the  skin,  cellular  tissue,  and  exposing  the  muscular  fibres.  The  fascia 
is  divided  upon  a  grooved  director,  and  the  search  for  the  artery  com- 
menced i'roin  the  fibres  of  the  biceps  muscle.  Looking  inward  from  this 
muscle,  a  large  nerve  is  met,  which  is  recognized  ns  the  median,  and 
immediately  within  and  behind  il  will  be  found  the  artery.  If  the  inci- 
lion  be  made  upon  the  inner  border  ol  the  biceps  muscle,  in  the  vicinity 
of  the  elbow,  the  artery  maj  be  found  upon  the  muscular  aide  ol  the 
iii  i re,  or  din  rtlv  behind  it 

Iron  tin  clavicle  to  the  insertion  of  tin  great  pectoral  muscle,  the 
continuation  of  the  brachial  artery  upward  is  called  axillary.  ] 
t«i  v  liei  "0  tin-  ;mt.  ri'.r  portion  "I  ill''  armpit,  running  under  the  pec- 
major  and  minor  muscles  (plate  16,  fig.  4 — 1,  2),  surrounded  by 
veins  and  nerves  ;  the  chief  vein,  h,  being  upon  its  under  and  anterior 
surface,  while  the  • 

Qg 


506  LIGATION    OF    AXILLARY    ARTERY. 

\ « r:il  large  branches  are  given  off  from  the  main  trunk  to 
■apply  the  shoulder,  back,  and  efaeat  Tbe  inferior  third  of  tho  art*  rj 
below  the  peotoralla  minor  nuuele  i-  tin-  only  portion  upon  wbi 

ligation   ie  attempted.     When  the  arm  is  carried  outward  from 
the  body, the  artery  ka  found  lying  npon  the  inner  border  of  tbe  i 
braehJadu  muaele,  '*.  having  two  nerves  upon 

external  cutaneouo,  e,  and  the  median,  d.  If  tbe  space  between  the 
:  the  great  pectoral  and  gn  at  dorsal  muscles  be  dh  ided  int<> 
three  parte,  tbe  axillary  arterj  «  ill  be  fonnd  oouraing  over  the  ju notion 
of  the  anterior  and  middle  third,  wben  an  incision,  of  three  inches  in 
length,  after  cutting  through  >k in  and  superficial  fascia,  will  And  it. 
The  ineiaion  baring  bean  made  (plate  18,  the  fasoia  divided 

upon  tbe  grooved  director,  the  inner  border  of  the  ooraoo-braohialls  is 
sought.  From  1 1 1  i ^  herder  aa  u  landmark,  the  oollnlar  tissue  la  torn  by 
tho  point  of  the  grooved  director.  Searching  inward,  the  fir.-t  white 
cord  which  makes  i t ^  appearance  i.-  the  external  ontaneous  nerve  :  v<  rj 
near  this  appears,  the  second  nerve,  the  median:  further  inward  we 
would  find  the  ulna  nerve;  then  the  internal  cutaneous.  It  is  after  the 
second  nerve,  or  between  and  behind  the  median  and  ulna,  that  the  ar- 
tery will  be  found. 

There  is  an  opcrattVi  laid  down  in  tbe  books  for  securing  the  axillary 
artery  on  the  inner  6ide  of  the  peetoralia  major  muscle.  Just  before  the 
vessel  passes  under  the  clavicle  to  beoome  subclavian,  the  arterj  is  ao 
covered  by  it."-  very  large  v<  in,  and  gives  off  such  large  branches,  thai 

the    result!    "f   ligation    are    D8Ually  fatal,    and   therefore  the   operative 

procedure  need  not  be  deacribed.      In  plate  20,  fig.  -1 — 1,  is  seen  an  in- 
cision, four    inches  in  length,  under  and  parallel  with  the   clavicle,  ex 
tending  outward    from    the  vicinity  of  the  Bterno-olavioular  junction. 
Tho  .-kin,  cellular  tiwoi  peotoral  muaele  are  divided,  when 

■ell  will  be  fonnd  beneath  the  great  pectoral  muaele  with  ita 
lar^e  vein  upon  it:-  anterior  surface,  both  embedded  in  loose  cellular 
tissue. 

Through  tho   lower   region  of  the  neck  passes    the  largo  aubelaoicui 

artery.      <»n    the   right    side,  this    veaael    is    of   the   bifurcating 

branches  of  the  arteria  innominataj  on  the  left  side  >t  arises  as  an  m- 

dopendant  branch    fi the  aroh  of  the  aorta.     The  arterj   m 

oorve  through  the  neck,  running  fi tbe  att  r Navicular  junction  to 

the  middle  ol    the  cla  \  ieh-,    w  here  It     pfl  In.-  bone  to  beOOBM 

axillary,  and  henoe  the  name  "t  aubclai  to  it.     The  artery, 

about  five  inches  in  length,  forma  a  bow,  ol  which  the  claviole  forms  tbe 
cord.  It  lies  deeply  at  the  root  of  the  in  ek,  covered  in  by  skin,  platysma- 
myoid,  aterno-oleido-maatoid,  omo-hyoid,  Chii 

last  muscle,  the  Boalenui  antiot  tohmenl  to  tbe  tu- 

■  the  middle  thud  ol  the 


LIGATION    OF   SUBCLAVIAN    ARTERY.  -ri07 

subclavian  artery,  thus  dividing  it  into  three  portions — a  p;irt  within  the 
muscle,  between  its  inner  border  and  the  sterno-clavicular  junction  ;  a 
second  portion  behind  the  scalenus  muscle;  and  a  third,  or  longer  por- 
tion, between  the  scalenus  muscle  and  the  upper  border  of  the  clavicle. 
From  the  inner  and  middle  portions  so  many  large  branches  are  given 
off  that  it  is  impossible  to  obtain  a  sufficient  space  between  the  scat  of 
ligature  aud  one  of  these  branches  to  obtain  a  successful  result  after 
ligation.  It  will  not  be  neeessary,  therefore,  to  study  the  relations  of 
tbese  portions  of  the  subclavian  artery.  It  is  upon  the  outer  portion  of 
the  vessel,  after  it  has  escaped  from  between  the  two  scalcni  muscles, 
that  successful  ligations  are  practised.  Usually  no  branches  arise  from 
this  outer  third  of  the  vessel.  The  subclavian  vein  (plate  20,  fig.  8,  B) 
accompanies  A,  the  subclavian  artery,  being  upon  its  anterior  face, 
and  separated  from  it  by  the  anterior  scalenus  muscle — the  artery 
passing  behind  the  vein,  which  lies  in  front  of  this  muscle.  No 
nerve  accompanies  immediately  this  artery,  although  the  entire  brach- 
ial plexus  of  nerves,  I),  issuing  from  the  four  inferior  cervical  foramina* 
pass  to  the  arm  at  a  short  distance  from  the  outer  border  of  this 
vessel.  Both  artery,  vein,  and  nerves  are  found  in  a  deep  triangular 
space  bounded  below  by  the  clavicle,  and  on  the  inuer  side  by  the 
external  border  of  the  stcrno-cleido-mastoid,  4,  or  the  anterior  scalenus 
muscle.  The  upper  and  outer  boundary  is  formed  by  the  omo-byoid 
muscle,  5;  the  outer  directly  by  the  trapezius  muscle.  The  immediate 
guide  for  finding  the  artery  is  the  tubercle  upon  the  upper  .face  of  the 
first  rib,  upon  which  prominence  is  attached  the  scalenus  auticus  muscle. 
Iu  ligating  the  subclavian  artery  at  its  outer  third,  which  is  the  only 
practicable  portion,  the  shoulder  to  be  operated  upon  must  be  depress- 
ed, the  face  being  turned  away  from  it.  The  skin  of  the  neck  is  drawn 
down,  parallel  with  the  clavicle,  for  half  an  inch,  and  an  incision  out- 
ward, three  inches  in  length,  is  made  on  the  upper  edge,  and  parallel 
with  the  clavicle,  extending  from  the  external  border  of  the  sterno- 
lid  muscle  to  tin  anterior  border  of  the  trapezius  muscle. 
The  incision  at  first  passes  through  the  skin  alone.  At  its  inner  angle 
is  seen  the  external  jugular  vein,  passing  down  on  the  outer  border  of 
the  Bterno-cleido-mastoid  muscle  to  empty  into  tho  subclavian  vein.  This 
vessel,  when  exposed,  ii  drawn  to  the  inner  aide  of  the  wound.  Should 
it  have  bean  injured  in  the  first  incision,  two  ligatures  arc  applied  to  it, 
and  the  vessel  divided  between  them.  The  next  tissue  divided  is  the  pla 
tysma-myoid;  then  the  cervical  fascia,  divided  upon  a  grooved  direotor. 

As  all  of  the  resistant  tissues  have  now  been  divided,  n  grooved  direct. »r 
ir  substituted  for  the  knife,  and  by  holding  it  firmly  near  its  point,  the 
cellular  tissue  is  torn  by  the  to  and  fro  movemi  nts  which  isolate  the  ves- 

I  he  index  I.  •  ry  well  effect    this   tearing  of  the  c.  llular 

tissue.     Should  the  km:  r  thit  purpose,  the  supra-scapular 


508  LIGATION    <>!■'   CAROTID    AKTKUY. 

artery,  which  runs  from  the  inner  half  of  the  subclavian  outward,  parallel 
with  the  upper  border  of  the  clavicle,  may  be  injured.  Having  now  free 
access  to  the  depth  of  the  wound,  the  left  indei  6nger  of  the  Burgeon  is 
thrust  into  the  wound,  tli>'  pulsation  in  the  artery  found,  nn-l  the  tubercle 
upon  the  upper  face  of  the  first  rili  sought  When  found,  the  finger  is  kept 
upon  it  tn  mark  its  situation,  while  an  aneurism  needle  is  guided  by  it 
to  the  depth  <if  the  wound,  and  by  placing  the  blunt  point  of  this  needle 
in  front  of  the  outer  border  of  this  tubercle  and  scraping  it  upon  the  rib 
immediately  from  before  backward,  the  artery  is  hooked  up,  as  it  is  the 
only  structure  lying  upon  the  rih  upon  the  outer  Bide  of  the  tub 
plate  20,  fig.  -1 — 2.  The  vein  is  separated  from  the  artery  by  the  thick- 
the  Boalenus  musole,  and  therefore  can  no)  be  included  in  the 
ligature.  Should  the  point  of  the  needle  not  be  retained  in  contact 
with  the  tubcrdc  of  the  rib,  but  be  allowed  to  wander  about  the  wound, 
niic  of  the  brachial  plexus  of  nerves  will  must  probably  be  hooked  up. 
The  aneurism  needle  having  been  threaded  before  it  was  appli 
end  of  the  thread  is  drawn  out  of  the  eve  upon  the  outer  side  of  the  l  es- 
sel,  and  )>\  drawing  the  instrument  backward,  the  exposed  thread  being 
held,  the  other  end  is  drawn  out  of  the  wound  with  the  needle,  leaving 
the  ligature  under  the  artery.  By  drawing  slightly  upon  this  it  can  be 
readily  determined  whether  the  artery  ii  over  the  thread  or  not,  as  the 
pulsation  in  it  would  in-  stopped  by  tin-  pressure.  Peeling  assured 
that  the  artery  alone  bs  tred,  the  Ligature  is  firmly  tied  by 

thrusting  Uie  fingers  deeply  into  the  wound.     One  end  of  the  ligature 

is  cut  (iff  close  to  the  knot,  the  other  brought  out  of  the  wound,  and  the 

inei.-ion  closed  by  But  u 

I.ioation  OF  THB  COMMON  CAROTID.  In  examining  the  outer  surface 
of  the  neck,  when  the  Bhoulder  is  drawn  downward,  the  jaw  thrown  up- 
ward, with  the  faoe  toward  the  opposite  Bhoulder,  a  muscular  ridge  la 
Been  running  diagonally  across  the  Deck  from  the  sternum  below  to  be- 
hind the  ear  above.  This  ridge  is  the  storno  oleido-mastoid  muscle, 
whioh,  from  its  position,  divides  the  Deck   into   two  triangles.     <>nc, 

bounded  by  this  ridge,  the  anterior  median  line,  and  the  lower  border 
ot  the  jaw,  is  I  lie  anterior  cervical  triangle,  which  contains  the  eat -lid 
artery  and  all  of  its  important  branches.  In  the  outer  triangle  bound- 
ed   by  this  ridge,  the  Clavicle,  and  the   anterior   border   of   the    trapc/.ius 

.  lies  the  Bubolaviari  vessels.     It  the  neck  be  dissected, 

by  the  removal  of  the  skin,  cellular  tissue,  plat\sina- 
myoid    muscle,   and    cervical    fascia,    the   lower   portion    of    the   sterno- 

oleido-mastoid   musole  will  lie  fonnd  to  cover  all  of  the  vessels,  the 

oommon  carotid  artery  being  deeply  seated  at  tho  root  of  the  nock. 

About  the  middle  of  the  neck  the  carotid  vessel  appears  from  beneath 

rder  of  the  muscle,  lying  in  a  groove  between  the  trachea 


LIGATION    OF   CAROTID    ARTERY.  509 

and  larynx  in  front  and  the  vertebral  column  behind,  having,  in  the 
cellular  sheath  which  envelopes  the  vessel,  the  large  internal  jugular 
vein  upon  its  outer  and  anterior  surface,  and  the  important  pneumogas- 
tric  nerve  between  and  behind  the  artery  and  the  vein.  A  branch  of 
the  hypo-glossal  nerve,  called  the  descendens  noni,  lies  in  front  and 
upon  the  sheath  of  the  vessel,  while  behind  the  sheath  is  the  sympa- 
thetic nerve.  If  the  sterno-cleido-mastoid  (plate  20,  fig.  1 — 3)  be  re- 
moved, this  anterior  trianglo  of  the  neck  is  found  subdivided  by  the 
oblique  position  of  the  omo-hyoid,  2,  forming  an  inferior  and  a 
superior  triangle.  In  the  lower  triangle  the  common  carotid  vessel, 
A,  plate  20,  fig.  1,  is  deeply  seated,  accompanied  by  the  internal 
jugular  vein,  B,  and  pneumogastric  nerve,  C.  No  branches  are 
given  off  from  it.  In  the  upper  triangle  it  becomes  more  superficial. 
Here  its  pulsation  can  readily  be  felt,  and,  as  the  vessel  is  nearly 
subcutaneous,  can  also  be  seen.  When  the  common  carotid  reaches 
the  level  of  the  thyroid  cartilage  it  bifurcates  into  two  vessels, 
the  internal  and  external  carotid.  The  internal  becomes  again 
deeply  seated,  entering  the  skull  through  the  temporal  bone.  The  ex- 
ternal commences  at  once  to  give  off  branches,  the  first  of  which,  the 
superior  thyroid,  runs  obliquely  downward  and  forward,  to  be  spent  upon 
the  thyroid  gland,  on  the  anterior  surface  of  the  trachea.  A  second, 
the  lingual,  runs  outward,  parallel  with  the  hyoid  bone,  to  be  spent  in 
and  about  the  tongue.  A  third,  the  facial,  E,  runs  an  obliquely  upward 
and  forward  course  over  the  lower-jaw,  to  be  distributed  upon  the  face. 
The  continuation  of  the  external  carotid  upward  terminates  finally  into 
two  branches,  the  internal  maxillary,  which  passes  on  the  inner  side  of 
the  head  of  the  lower  jaw,  and  is  the  artery  often  injured  in  the  re- 
moval of  this  bone;  and  the  temporal  artery,  coursing  upward,  in 
front  of  the  ear,  to  be  distributed  to  tho  anterior  portion  of  the  scalp. 

In  ligating  the  common  carotid  artery,  the  storno-cleido-uiastoid 
muscle  is  used  as  a  guide  to  find  the  artery.  The  vessel,  at  its  origin,  lies 
under  this  muscle,  but  always  escapes  from  beneath  its  inner  border  at 
the  middle  of  the  neck,  and  then  courses  upwards  to  the  lower  jaw,  in 
the  direction  of  and  nearly  parallel  with  its  inner  border.  The  chest 
being  raised  by  a  pillow  placed  between  the  shoulders,  head  depressed, 
and  face  turned  toward  tin-  opposite  shoulder,  with  angle  of  jaw  turned 
upward,  so  that  a  Btrong  light  falls  upon  the  neek.  an  incision,  three 
inches  in  length,  is  made  upon  and  parallel  with  the  inner  border  of 
the  ido-mastoid    muscle    (plate    20,   fig.    2,    a).      It   passes 

through  the  skin,  cellular  tissue,  platysma-myoid  muscle,  and  superficial 
ia,  exposing  the  fibres  of  the  Bterno-cleido  mastoid   muscle,  which 
:ir,    ,,t  .  .     they  run  always   in  an  oblique  direction, 

upward  "»</  bat  I  he  only  otl  rhiota  may  confuse  the 

ratoi  i-  the  platysma-myoid,  the  fibres  of  which  run  always  npi 


BIO  T.ldATloN    OF   ARTERIES. 

and  forward.  It  is  always  preferable  to  cul  down  upon  rather  than  at 
the  inner  side  of  the  Bterno-cleido-mastoid  muscle,  as,  when  exposed, 
it  can  be  used  as  a  sure  guide;  and  also,  by  it-  thickness,  protects  the 
vessels,  etc.,  beyond  it.  When  the  deep  layer  of  cervical  fascia  is 
divided  upon  the  grooved  director,  the  inner  border  of  the  muscle  is 
drawn  outward  by  an  assistant,  when,  with  the  linger,  the  pulsation  <>f 
the  artery  can  be  felt  under  its  sheath,  upon  which  can  now  bo. 
seen  a  small  white  thread — the  deseendens  mini  nerve.  The  cellular 
tissue  forming  the  sheath  is  carefully  picked  up  by  a  forceps, 
and  opened  by  the  poiut  of  tut;  knife  held  horizontally  ;  great 
care  being  taken  not  to  mistake  the  structure  of  the  vein  for  the 
sheath — the  latter  will  be  known  by  its  dark  appearance  when  filled 
with  blood — nor  should  the  small  nerve  upon  the  sheath  bo  injured. 
Upon  a  grooved  director,  carefully  inserted,  the  sheath  is  divided. 
With  the  point  of  the  director  the  vein  is  separated  from  the  artery, 
using  a  forceps,  upon  the  contiguous  sheath  and  not  upon  the  vein,  to 
steady  the  parts  while  the  cellular  connections  between  the  vessels  are 
torn.  An  aneurism  needle,  threaded,  is  now  passed  from  without 
inwards  around  the  artery — care  being  taken  not  to  include  the  pneii- 
inogutrio  nerve,  which  lies  between  and  behind  the  vessels,  imr  the 
deseendens  noni,  which  runs  on  the  anterior  surface  of  the  sheath. 
The  needle  should  always  bo  entered  between  the  vein  and  artery, 
and  by  a  winding  or  worming  movement  is  made  to  work  its  way 
through  the  cellular  tissue  forming  the  bod  of  the  vessel.  After  the 
thread  is  passed  under  the  vessel  it  must  be  drawn  upon,  to  determine 
whether  it  has  been  applied  to  the  artery,  which  is  proved  by  the  pul- 
sation ceasing  below  it.  The  vessel  is  then  tied  firmly  by  thrusting 
the  tinkers  into  the  wound  and  making  traction  Ogainsl  the  pulps  of 
the  two  index  lingers.  One  end  of  the  ligature  is  cut  oil"  near  the  knot, 
the  other  secured  to  the  surrounding  skin  of  Hie  neck  under  a  piece  of 
adhesive  plaster,  and  the  wound  closed  by  sutures. 

When  it  is  necessary  to  ligate  the  external  carotid  artery,  a  similar 
incision,  extending  upward,  but  still  upon  the  inner  border  of  the 
Hterno-cloido-inastoid  muscle,  will  equally  expose  the  vessel  in  the 
vicinity  of  the  posterior  extremity  of  the  hyoid  bone,  where  either  the 
common  trunk,  the  internal,  or  external  carotid  can  bo  liguted. 

Some  of  the  branches  of  the  external  carotid  sometimes  require 
ligation,  either  from  the  direct  effects  of  injury,  or  from  secondary 
hemorrhage. 

The  superior  thyroid  artery,  the  first  branch  given  off  from  the  ex- 
ternal carotid,  can  be  exposed  in  the  wound  for  the  ligation  of  the 
common  carotid  at  its  bifurcation.  The  artery  lies  between  the  sheath 
Of  the  carotid  vessel  and  the  lateral  lobe  of  the  thyroid  gland,  where 
it  can  be  found. 


LIGATION   OP   ARTERIES.  511 

The  lingual  artery  is  so  deeply  seated,  covered  by  Uio  hyoid  and 
lingual  muscles,  that  its  pulsation  can  not  be  felt.  The  guide  for 
this  vessel  is  the  upper  border  of  the  hyoid  bone,  parallel  to  which, 
and  half  an  inch  above  it,  an  incision  of  one  anil  a  half  inches  Bhould 
bo  made.  This  incision  exteuds  through  the  skin,  platysma-myoid,  and 
cervical  fascia,  which  exposes  the  tendon  of  the  digastricus  muscle — 
plate  20,  fig.  b — a.  The  incision  is  continued  above  this  tendon  through 
the  hyo-glossus  muscle,  uudor  whicli  the  artery  is  found  resting  upon 
the  gcnio-hyo-glossns  muscle,  and  accompanied  by  tho  hypo-gloss:il 
nerve.  The  facial  artery,  as  it  runs  over  the  lower  jaw  in  front  of  the 
masseter  muscle,  cau  be  readily  felt  and  secured  by  making  an  incision 
parallel  with  the  anterior  border  of  the  masseter  muscle,  the  vessel 
lying  very  superficially.  In  front  of  the  ear  the  temporal  artery  can 
be  roadily  felt,  where  its  courso  is  subcutaneous  over  the  posterior  and 
outer  edge  of  the  zygomatic  arch.  An  incision  of  one  inch  in  length, 
passing  through  the  skin,  will  expose  the  artery  embedded  in  a  con- 
densed cellular  tissue. 

In  cases  where  persistent  hemorrhage  occurs  from  the  passage  of  a 
ball  implicating  any  of  these  vosscls,  it  is  preferable  at  all  times  to 
enlarge  the  wound,  seek  the  bleeding  vessel,  and  ligate  it  in  situ, 
rather  than  ligate  the  main  vessel,  which  should  always  be  considered 
a  dernier  resort. 


LIGATION  OF  ARTERIES  OF  TTIE  INFERIOR  EXTREMITY. 

In  the  inferior  extremity  we  find  a  similar  distribution  of  blood - 
to  that  of  the  superior  limb.  The  artery  which  passes  through 
the  pelvis  as  iliac,  becomes  femoral  as  it  courses  through  the  thigh, 
then  popliteal  behind  the  knee,  where  it  divides  into  two  main  trunks. 
Ono  perforates  the  upper  portion  of  the  interosseous  membrane  between 
the  tibia  and  fibula,  to  become  anterior  tibial,  running  down  to  the  foot 
as  dorsalis  pedis:  the  other  passes  through  the  back  of  the  leg  as 
posterior  tibial  vessel,  and  running  behind  the  inner  malleolus  supplies 
the  plantar  muscle  as  plantar  artery.  Soon  after  its  origin  the  poste- 
rior tibial  artery  gives  off  a  large  branch — the  peroneal  artery — which 
runs  down  the  limb  on  the  inner  and  posterior  border  of  tho  fibula, 
passing  into  tho  sole  behind  the  external  malleolus. 

In  examining  plate  17,  fig.  1,  the  d  Malta  pedis  artery,  the  continua- 
tio  i  of  tlie  anterior  tibial  vessel,  A.  is  seen  running  superficially  upon  tho 
back  of  the  foot,  having  passed  bauoath,  1,  the  annular  ligament.  Its 
Course  is  a  straight  one  from  the  mi  Idle  of  the  space  between  the  two 
malleoli  to  the  IntermetatarsaJ  space  between  the  first  and  second  toes 


512  LIGATION    OF   TIBIAL   ARTERY. 

The  artery,  accompanied,  U  usual,  by  two  veins  ami  a  nerve,  lies  in  ;m 
intermuscular  spare  upon  the  deep  extensors  of  the  toes,  1.  havii 

iii8or  of  the  toes,  3,  upon  its  outer  border,  and  the 
proper  extensor  of  the  big  toe,  2,  upon  its  inner  side.  The  guide  for 
ligating  this  artery  is  either  in  make  an  incision  (plate  17,  fig.  2)  upon 
the  outer  side  of  and  parallel  with  the  tendon  "f  the  extensor  propria! 
poliiois — which  tendon,  when  pat  in  action,  forms  a  cord  under  the 
skin,  upon  the  anterior  and  inner  Side  of  the  foot— or  in  a  line  'Irawn 
from  the  middle  of  the  instep  to  tin-  Interspace  between  the  big  and 
second  toe.  An  incision  through  the  skin  and  cellular  tissue  at  onod 
ezpoBBS  the  vessel.  Should  any  doubt  arise  as  to  its  exact  locality,  by 
searching  from  the  outer  edge  of  the  tendon  of  the  proper  extensor  •!" 
the  big  toe  the  artery  can  always  he  found. 

The  anterior  tibial  artery  (plate  17,  fig.  3,  A),  accompanied  by  its 
veins,  B  B,  runs  nearly  a  straight  course  upon  the  anterior  surface  of 
the  interosseous  membrane,  being  very  deeply  seated  above,  but  becom- 
ing more  superficial  as  it  descends,  until  at  the  instep  its  position  over 
the  anterior  face  of  the  inferior  extremity  of  the  tibia  is  nearly  subcu- 
taneous. In  the  upper  half  of  the  leg  the  anterior  tibial  artery.  .1. 
eeply  in  the  intermuscular  space  formed  by  the  body  of  the 
tibialis  anticus  muscle,  4,  upon  the  inner  side,  and  the  extensor  commu- 
nis digitorum  pedis,  6,  upon  the  outer  side.  The  tibial  nerve,  '',  here 
lies  upon  the  outer  side  of  the  artery.  In  its  lower  half  the  artery  is 
placed  between  the  tibialis  anticus  mUBCle,  Land  the  extensor  pollicis 
pedis,  S,  the  anterior  tibial  nerve,  c,  lying  often  upon  the  anterior  face 
Of  the  artery,  and,  at  times,  even  gaining  its  inner  border. 

In  ligating  the  anterior  tibial  artery  in  any  portion  of  its  extent,  sev- 
eral guides  can  be  used.  One  of  these  is  the  tendon  of  the  tibialis  ami- 
cus muscle,  which,  when  put  upon  the  stretch,  tonus  a  prominence  un- 
der I  he  skin  of  the  leg  ;  an  incision  made  upon  the  outer  b  irder  of  this 
cord-like  prominence  will  always  find  the  artery.  Another  guide  is  to 
allow  a  certain  thickness  for  the  belly  and  tendon  of  the  tibialis  anticus 
muscle,  and  make  tin'  incision  correspondingly,  which  allowance,  in  a 
lleshy  Bubjeot,  should  be  three  fingers'  breadth  from  the  anterior  edge 
of  the  tibia  in  the  upper  third  of  the  leg;  two  fingers'  breadth  in  the 
middle,  and  one  finger  breadth  in  tin'  lower  third  of  the  leg,  where  the 
tendon  alone  separates  it  from  the  tibia.  Still  a  third  guide  is  a  straight 
line  drawn  from  a  point  midwa\  between  the  head  of  the  fibula  and  an- 
terior spine  of  the  tibia,  and  a  point  midway  betweon  the  malleoli.  An 
inoi8ion  made  in  any  portion  of  this  line  will  expose  the  artery.  I  sing 
any  of  these  guides  (for  they  all  correspond  with  each  other),  an  inci- 
sion is  made  (plate  17.  flg,  1  —  2)  lour  inches  in  length,  in  the  upper 
part  of  the  leg.  extending  through  the  skin,  cellular  tissue,  and 
aponeurotic  fascia   which    binds   down  the  muscles.     As  the  longitu- 


LIGATION    OF    TIBIAL    ARTERY.  513 

dinal  incision  through  this  Fascia  is  usually  not  sufficient  to  allow 
of  a  free  search,  a  cross  incision  is  made  into  it,  extending'  from  the 
spine  of  the  tibia  outwards,  one  inch  in  length.  The  intermuscular 
space  not  being  clearly  defined  in  the  upper  portion  of  the  leg, 
is  readily  determined  by  placing  the  index  finger  in  the  wound  with 
the  tip  resting  upon  the  spine  of  the  tibia.  As  the  finger  is  drawn 
outward,  pressing  at  the  same  time  upon  the  muscle,  a  mass  of  muscu- 
lar tissue,  the  belly  of  the  tibialis  anticus,  is  felt  to  roll  away  from  the 
tinker,  which  at  once  sinks  into  a  depression  or  groove  corresponding  to 
the  intermuscular  space  between  this  and  thecomniou  extensor  muscle. 
With  the  grooved  director  or  index  finger  the  two  muscles  arc  separated 
in  this  gutter,  and  after  passing  to  the  depth  of  nearly  two  inches,  the 
artery,  with  veins  and  nerve,  are  found  lying  upon  and  intimately  con- 
nected to  the  interosseous  ligament.  With  the  point  of  the  grooved 
director  the  artery  is  isolated  from  the  accompanying  veins  for  a  suffi- 
cient distance,  one  or  two  lines,  to  allow  the  passage  of  the  aneurism 
needle,  armed  with  a  ligature.  A3  there  are  no  vessels  of  any  size  to 
be  divided  in  this  operation,  the  incision  can  be  bold,  and  the  opera- 
tion is  comparatively  a  dry  one,  without  loss  of  blood.  In  the  lower 
portion  of  the  leg  the  operation  is  conducted  in  the  same  way.  After 
an  incision  of  two  to  three  inches  in  length  through  the  skin  and  (plate 
17,  fig.  4 — 1)  superficial  fascia,  the  finger  is  placed  upon  the  spine  of 
the  tibia  and  drawn  outwards.  When  one  cord  escapes,  we  know  that 
it  is  the  first  and  only  muscle  intervening  between  the  bone  and  the 
artery,  and,  therefore,  upon  its  outer  side  we  will  invariably  find  the 
resseL 

The  potterior  tibial  arttry  also  runs  a  straight  course  upon  the  back 
of  the  leg,  lying  deeply  embedded  in  the  upper  half  of  the  limb,  between 
the  deep  and  superficial  layers  of  muscles.  Approaching  the  surface  &e  1; 
descends,  when  near  the  ankle,  it  lies  under  the. skin  and  fascia,  without 
muscular  covering.  From  its  origin  in  the  inferior  portion  of  the  popli- 
teal space,  the  posterior  tibial  artery  (plate  1  B,  fig.  1,  A)  lies  under  the 
calf  muscles,  ...  composed  of  the  gastrocnemii  and  soleus,  uniting  to  form 
below  the  tendo  achillis,  6.  The  artery,  accompanied  by  two  reins,  />. 
one  on  cither  side,  and  the  posterior  tibial  nerve,  c,  lies  beneath  the 
deep  fascia,  ami  upon  the  deep  flexor  muscles  of  the  foot  and  leg  To 
expose  the  artery  in  the  upper  half  of  the  leg.  the  soleus  muse], 
detached  from  the  inner  hordcr  of  the  tibia  and  drawn  outward  with  a 
hook,  as  in  fig.  1,  5.  As  the  artery  in  its  descent  appears  from  i  11 
the  inner  border  of  the  soleus  muscle,  becoming  comparatively  -nper- 
ficial.  it  lies  in  the  inierinus -nlar  spaot  between  tin'  tendo  aehilli.-,  fi. 
and    the  flexor  communis  digitorum,  8,  the  tendon  .>f  which  mat 

reachinj  1  f  the  foot,  passes  through  .1  .^heatii  behind  the  inner 

malleolus,  2. 


:.|  1  LIGATION    01    FIBULAR    AUTKUY. 

To  Ligate  this  rend,  the  leg  is  placed  on  Ita  oater  side,  with  knee 
flexed,  and  .-in  Incision  i<  made  parallol  with  and  one  inch  from  the  in- 
nor  and  posterior  border  ol  the  tibia,  it'  the  ligation  la  performed  In 
the  npper  half  of  the  leg;  and  midway  between  the  tibia  and  tendo 
achillls,  if  in  the  lower.     A.-  the  posterior  tibial  art<  i  nto  tho 

foot,  it  can  be  found  midway  between  tho  internal  malleolus  and  the 
bony  prominence  upon  the  Inner  border  < ■  f  the  oaealcis,  in  thooentn  of 
the  hollow  of  the  heeL  In  the  lower  portion  of  the  leg  the  inoision 
should  be  two  and  a  half  inehea  in  length  ;  plate  18,  Bg  2-  1 1,  extending 
through  tin-  skin,  oellulat  tissue,  end  faula.  When  the  d 
divided  upon  the  grooved  direotor,  and  the  finger  thrust  into  the  wound 
i  position  of  the  vessel  ean  be  discovered  by  its  pulsation,  and 
by  means  of  the  end  of  the  grooved  director  it  ean  he  suflieiently  iso- 
lated for  the  passage  of  tho  aneurism  needle,  bom  its  oontiguona  veins 
and  posterior  tibial  nerve,  which  lie-  upon  its  outer  side. 

In  the  Upper  half  of  the  leg  the  artery  is  niueh  deeper  seated,    lying 

between   the   deep  and  superficial  Layers  of  musolos,  under  th 

faSCis  Ol  tlie  leg  and  under  the  middle  of  the  calf.  As  from  the  depth  of 
the  around  and  the  inconveniences  of  cutting  through  the  centre  of  the 

call,  both  from  injury  to  the  muscles  and  from  the  accompanying 
orrhage,  it  would  he  improper  to  cut  down  directly  upon  the  course  of 

■  ■!.  an    incision  of  four   inches,  or  even  more,  ill  extent,    la  made 

upon  the  Inner  side  of  the  lag  (plate  18,  fig.  -  -3),  parallel  with  and 
one  inch  from  the  posterior  border  of  the  tibia.  The  incision  is  made 
boldly  through  the  skin  and  cellular  tissue  to  the  musoular  fibres  of 
the  toleua  musolo.  Detach  this  muscle  from  ita  eonnectiona  with  the 
tibia,  and  have  it-  border  drawn  backwards  (plate  is,  tig.  i— 5).  if 
the  ironnd  be  thoroughly  oleansed,  the  vessels  con  bo  seen  aa  well  as 
the  pulsation  in  the  artery  felt,  under  the  deep  fascia,  having  a  vein 
.  ii  each  side,  and  the  tibial  nerve  upon  it.,  cater  border.  Thi 
fascia  is  divided  upon  a  grooved  director,  the  vessel  Isolated,  and  the 

in  needle,  armed  with  a  ligature,  passed.      This  operation,  owing 

to  the  depth  of  the  wound,  la  one  of  the  most  troublesome  and  tedious 

of  the  ligation-. 

The  fibular  or  peroneal  artery,  an  external  and  posterior  bifurcation 
of  the  posterior  tibial,  descends  vertically  along  the  posterior  and  inter- 
nal horder  of  the  til  ml  a,  throughout  its  entire  length,  being  deeply 

covered  in  by  the  aoleua  console  above  and  by  the  tibialis  posticua  and 

proper  llexor  of  the  great  toe  in  the  lower  half  of  its  course.      To  ligate 

-.1  the  leg  i-  placet  upon  its  Inner  surface,  and  an  inoisi 't 

four  Inohea  in  length  la  made  parallel  With  and  one-fourth  of  an  inch 
from  tin'  externa!  horder  of  the  fibula.  This  incision  extends  through 
tin-  Integumentary  tissm  the  masole.     If  the  operation  is 

performed  in   the  upper  half  of  the  leg.  I  he  Boleua   muscle  must   I 


LIGATION    OF   FEMORAL    ARTERY.  515 

tached  from  its  fibula  connection  and  drawn  outwards,  which  exposes 
the  flexor  longus  pollicis.  Detach  this  muscle  from  the  fibula  and  draw 
it  outwards,  when  the  peroneal  artery  will  be  found  at  its  inner  border, 
lying  upon  tbc  bone  near  the  attachment  of  the  interosseous  membrane 
(plate  17,  fig.  4—3). 

The  femoral  artery  requires  from  us  particular  attention,  as  its  liga- 
tion is  more  frequently  required,  both  in  civil  and  military  surgery, 
than  that  of  any  other  artery.  The  main  artery  running  through  tbo 
thigh  is  called  femoral  from  the  groin  to  the  knee.  The  abdominal 
aorta,  opposite  to  the  body  of  the  fourth  lumbar  vertebra,  bifurcates 
into  two  large  vessels,  which  run  off  obliquely  from  the  main  trunk. 
Those  are  the  common  iliacs,  which,  after  a  course  of  two  inches, 
when  they  reach  the  vicinity  of  the  sacro-iliac  symphysis,  subdivide 
into  two  other  vessels,  the  external  and  internal  iliacs.  The  external 
iliac  continues  onward  around  tho  brim  of  the  pelvis  until  it  passes 
from  the  abdomen,  beneath  Poupart's  ligament,  when  it  is  known  as  the 
femoral  artery.  Its  course  is  still  a  straightone,  shooting  down  the  limb, 
leaning  to  the  inner  bonier  of  the  thigh,  and  finally  winding  around 
and  behind  the  femur,  where,  as  popliteal  artery,  it  is  found  behind  the 
knee-joint.  Throughout  its  entire  course  it  is  accompanied  by  a  very 
large  vein,  the  femoral  vein,  which  is  always  placed  upon  its  inner 
border,  and  by  a  nerve,  which  lies  on  its  outer  side. 

In  examining  more  particularly  the  relations  of  the  femoral  artery, 
we  find  that  the  vessel,  with  the  femoral  vein  upon  its  inner  side,  and  a 
large  plexus  of  femoral  nerves  upon  its  outer  side,  passes  out  from  be- 
neath the  femoral  arch,  midway  between  the  anterior  superior  spinous 
process  of  the  ilium  and  the  symphysis  pubis.  At  this  point  the  pulsa- 
tion of  the  artery  can  be  distinctly  felt,  as  it  lies  upon  the  pelvic  bones, 
separated  from  them  only  by  the  psoas  and  iliacus  muscles,  which  form  a 
soft  bed  for  the  vessel.  Thcartery  is  here  quite  superficial,  covered  only 
by  skin,  cellular  tissue,  and  the  fascia  lata  of  the  thigh.  No  muscular 
pad  covers  the  vessel  ;  hence  the  facility  of  arresting  the  circulation 
through  the  thigh  by  pressure  at  this  point  whenever  operations  In- 
volving the  vessels  are  practised  upon  tho  inferior  extremity,  Plate  14, 
fig.  6.  shows  how  pressure  in  to  be  made  by  applying  both  thumbs  to 
the  pulsating  vessel,  Al't'T  its  esoape  from  beneath  Poupart' 
mi  nt,  the  femoral  artery,  throughout  its  oouree  through  the  thigh,  It 
placed  in  certain  relations  with  the  thigh  muscles.  Thesartorius  mus- 
cle, running  obliquely  from  the  outer  portion  of  the  hip  to  the  inner 
pari  of  the  knee,  where  ii  i-  attached  to  the  inner  face  of  the  head  of 
the  tibia,  is  called  the  satellite  of  thcartery.  In  tho  upper  fourth  of 
thethigfa  the  artery  lies  on  the  Inner  side  of  the  muscle,  In  the  second 
fourth,  a?  themueeie  runs  much  moreobliquely  inwards  than  the  artery, 
■  r  the  vessel,  which,  in  this  part  of  the  thigh,  lies  under  the 


516  LIGATION    or    FEMORAL   ARTERY. 

muscle.  In  the  third  portion  of  the  thigh  the  artery  is  actually  placed 
upon  the  (niter  side  nf  the  muscle,  inasmuch  as  the  sartorial  has  run 
over  the  arteryj  and  is  now  found  apon  the  inner  side  of  the  vessel.     In 

10,  lig.  2,  the  Bartorias  muscle  is  1 ked  up  and  drawn  outwards, 

to  sIkiw  the  vessels  running  under  it. 

In  the  upper  third  of  the  thigh,  as  the  femoral  artery  is  must  super- 
ficial, this  position  is  mosl  frequently  selected  for  the  application  of  the 

ligature.     The  Space  IS  called  the  triangle  of  Scarpa,  and  has  long) D 

the  sent  of  election  fur  tying  the  femoral  artery.  The  boundaries  of  this 
space  are  the  sartorius  muscle,  which  forms  a  prominent  ridge  upon  the 
(inter  and  anterior  border  of  the  triangle.  The  inner  border  i.-  formed 
by  the  adductor  longus  muscle,  which  is  attached  above  to  the  pubis, 
and  below,  upon  the  middle  of  the  rough  line  of  the  femur.  The  base 
of  the  triangle  is  formed  by  Pouparfs  ligament,  1.  Even  before  the 
skin  is  dissected  off  from  the  upper  part  of  the  thigh,  the  outline-  of  the 
triangle  can  bo  well  discerned.  The  line  of  the  groin  forms  the  base  :  the 
oblique  ridgo  upon  the  anterior  portion  of  the  thigh  the  outer  1. order  of 
the  triangle]  t he  inner  ridge  of  the  thigh  the  inner  boundary;  and 
where  these  two  ridges  intersect  inch  other  is  the  apex.  If  a  line  be 
let  fall  from  this  apex,  perpendicularly  to  Ponpart's  ligament,  it  will 
lie,  throughout  its  entire  extent,  over  the  course  of  the  femoral  artery. 
The  artery,  A,  will  he  accompanied  on  its  inner  side  by  the  femora] 
vein,  <\  which  adhere-  more  or  less  intimately  to  the  artery,  being 
separated  from  it  by  a  prolongation  of  the  fascia  lata  :  and  separate. 1 
from  the  artery  also  by  a  prolongation  of  the  fascia  lata,  is  a  large 
package  of  anterior  femoral  nerves.  A'.  From  one  to  two  inches  below 
the  fold  of  the  groin  the  femoral  artery  gives  oil'  a  very  large  branch) 
the  profunda  femoris,  which  at  on.e  Lories  itself  in  the  muscles  of  the 

thigh  to  supply  them  With  nutrition.       The  femoral  vessel  proper,  alter 

this  bifurcation,  passes  onward  to  the  knee,  giving  "if  no  branches  of 

importance  until  it  beoomes  popliteal,  when  it  commences  through  the 
terminal  branches,  which  we  have  already  studied,  a-  tibial  vessels,  to 
supply  the  leg  and  foot. 

In  ligating  the  femoral  artery  in  Scarpa's  triangle  the  position  of  the 
profunda  must  lie  remembered,  as  the  ligature  should  he  applied  at 
either  some  little  distance  above  or  below  this  vessel,  and  not  at  the 
bifurcation.  The  outlines  of  the  triangle  must  he  clearly  mapped  out, 
and  the  perpendicular  drawn  from  the  apei  of  the  triangle  to  the  centre 
of  Pouparfs  ligament,  which  line  will  correspond  to  the  pulsation  of 
the  artery,  and  also  to  a  line  which  will  mark  out  the  course  of  the  ar- 
tery when  the  limb  may  lie  so  swollen  or  fat  that  the  muscular  promi- 
nences may  not  he  discernible.  Thi*  line,  which  lies  over  the  entire 
course  of  the  femoral  artery,  is  one  drawn  from  the  middle  of  Pouparfs 
ligament,  or  from  midway  between  the  anterior  superior  supinous  process 


LIGATION    OF    FEMORAL    ARTERY.  517 

of  the  ilium  and  the  symphysis  pubis,  to  a  point  midway  between  the 
condyles  of  the  femur  behind  tbe  knee,  the  line  encircling  obliquely  the 
inner  portiou  of  the  thigh.  An  incision  from  three  to  four  inches  in 
length  is  made  upon  this  line  as  it  passes  through  the  centre  of  Scarpa's 
triangle — plate  19,  fig.  3.  This  incision,  after  passing  through  tho  skin 
and  cellular  tissue,  exposes  a  superficial  vein  called  the  interna]  saphe- 
nous (plate  19.  fig.  2,  d),  which,  running  up  from  tho  foot  and  leg, 
curses  upon  the  inner  surface  of  the  thigh,  and  one  and  a  half  inches 
below  the  fold  of  the  groin  enters  an  orifice  in  the  fascia  lata,  the  saphe- 
nous opening,  to  empty  directly  into  the  femoral  vein.  This  vein  must 
not  be  injured.  The  fascia  lata,  upon  its  outer  side,  is  pinched  up  and 
divided  upon  a  grooved  director,  which  exposes  at  once  tho  sheath  of 
the  vessel.  With  blunt  hooks  the  lips  of  the  wound  are  drawn  asunder 
by  an  assistant,  when  the  surgeon,  feeling  the  pulsation  and  seeing  tho 
vein  and  artery,  by  the  careful  use  of  the  end  of  the  grooved  direotor 
separates  the  vein  from  the  artery  for  a  sufficient  extent  to  pass  the 
threaded  aneurism  needle  between  tho  vein  and  artery,  with  point 
directed  outward,  and  hooks  up  the  artery.  Isolating  the  artery  from 
all  nerves,  and  feeling  assured  that  tho  ligature  passes  under  it,  the 
thread  is  tied,  and  the  case  treated  as  usual,  by  closing  the  wound  by  su- 
tures, and  applying  water  dressing  to  ensure  quick  union. 

Whether  that  portion  above  or  below  the  origin  of  the  profunda  re- 
quires a  ligature,  the  only  difference  in  the  operation  consists  in  the 
position  of  the  wound  upon  the  line  indicated — the  envelopes  of  the  ar- 
tery, and  its  relation,  both  to  the  femoral  vein  and  crucial  nerves,  being 
practically  the  same  in  both  situations. 

When  we  are  called  upon  to  tic  the  femoral  artery  at  the  junction  of 
the  upper  and  middle  thirds  of  the  thigh,  we  either  cut  in  the  imaginary 
line  drawn  from  the  middle  of  the  groin  to  the  middle  of  the  back  of 
the  knee,  or  it  the  sartorius  muscle  is  sufficiently  prominent,  an  in- 
cision of  from  three  to  four  inches  in  length  is  made  directly  upon  this 
muscle,  exposing  its  fibres  by  cutting  through  skin,  cellular  tissue,  and 
fascia.  We  recognize  the  musclo  immediately  by  tho  direction  of  iis 
as  in.  other  superficial  musole  of  the  thigh  has  fibres  running 
obliquely  downward  and  inward.  Knowing  exactly  where  we  are  by 
the  direction  of  these  fibres,  they  are  all  drawn  to  the  outer  Bide  of  the 
wound,  when  the  femoral  artery,  vein,  and  two  accompanying  nerves, 
will  be  found  under  its  inner  border,  covered  over  by  a  lay<  r  l  ; 
lata  and  the  propel  sin  nth  of  the  vessels. 

The  two   Berret   which   accompany  the  artery  are  the  internal  cuta- 

ind  the  lonj,'  saphenous.     When  the  artery  passes  through  the 

tendon  of  the  adductor  muscle,  at  the  junction  of  the  middle  and  interior 

thirds  of  tb<  thigh,  it  is  still  accompanied  by  the  long 

saphenous  nerve,  which  i  ridge  with  if,  while 


518  LIGATION    OF   ILIAC   ARTERY 

the  internal  cutaneous  passes  over  the  bridge,  and,  as  its  name  implies, 
is  distributed  to  the  skin  of  the  inner  portion  of  the  leg. 

Although  Beldom  required,  there  are  instances  in  our  military  ex- 
perience where,  from  injury  to  the  femoral  vessels  in  the  groin,  a  liga- 
ture to  the  ttiae  artery  is  deemed  necessary.  Plate  19,  fig.  1.  will 
exhibit  to  us  the  relations  which  the  external  iliac  artery  bears  t"  its 
surroundings.  The  entire  length  of  the  external  iliac  is  not  over  five 
inches,  extending  along  the  rim  of  the  pelvis  from  the  Bacro-iliao 
symphysis  to  Poupart's  ligament.  As  it  approaches  its  termination 
it  gives  off  two  large  branches,  the  epigastric  and  the  circumflex  arte- 
ries. On  its  inner  side  lies  the  iliac  vein,  and  without  a  number  of 
crural  nerves.  All  of  these  structures  lie  upon  the  psoas  and  iliac 
muscles,  covered  by  transversalis  fascia  and  peritoneum.  In  exposing 
the  artery,  an  incision  three  to  four  inches  in  length  is  commenced 
over  the  point  where  the  pulsation  of  the  art*  ry  is  distinguished  as  it 
runs  over  the  brim  of  the  pelvis,  being  parallel  with  and  half  an  inch 
above  Poupart's  ligament,  and  terminates  two  inches  above  the  anterior 
superior  spine  of  the  ilium.  The  incision  extending  through  the  skin. 
Superficial  fascia,  the  tendon  of  the  external  oblique  muscle,  and  the  in- 
ternal and  transversalis  muscles,  all  of  which  are  incised  upon  the 
grooved  director  for  safety,  exposes  the  traus\  crsalis  fascia. 

The  wound  is  now  dilated  with  the  two  index  fingers  of  the  surgeon 
separating  the  cellular  tissue,  and  pushing  inward  ami  upward  the 
peritoneum,  which  he  dissects  by  tearing  it  from  the  transversalis  fas- 
cia. AVhen  the  separation  is  carried  sufficiently  far,  the  operator,  keep 
ing  back  the  peritoneum  with  the  index  finger  of  the  left  hand,  thrusts 
the  forefinger  of  the  right  hand  into  the.  wound,  feeling  for  the  brim  of 
the  pelvis  and  the  pulsation  of  the  iliac  artery.  As  soon  as  permit- 
ted, the  wound  being  well  dilated,  the  operator  scratches  through  the 
loose  cellular  sheath  id'  the  vessels,  ami  passes  the  threaded  aneurism 
needle  from  within  outward,  the  point  being  first  inserted  between  the 
vein  and  the  artery,  to  avoid  injuring  the  delicate  coats  of  the  former. 
Ono  end  of  the  thread  is  drawn  out  of  the  wound  ;  the  withdrawal  of 
the  needle  with  the  other  end  of  tho  thread  encircles  the  vessel.  Being 
quite  sure  that  the  artery  alone  is  surrounded,  the  thread  is  tied  bj 
passing  Hie  forefingers  deeply  into  the  wound,  and  making  traction 
upon  the  noose  without  lifting  the  artery  from  its  bed.  One  end  of  the 
thread  is  cut  off  olose  to  the  knot,  the  othor  drawn  out  and  secured 
safely  upon  the  abdominal  wall,  the  wound  being  closed  by  sutures,  as 
in  all  instances,  and  (he  usual  oold  water  dressing  applied. 


OPERATION    OF   TREPHINING  519 


TREPHINING. 

In  compound  fractures  of  the  skull,  where  the  bones  are  much  spec- 
ulated, it,  has  lu'i'ii  already  recommended  to  remove  all  loose  fragments 
at  the  first  dressing.  Should  the  skull  have  been  driven  in,  depressed, 
with  accompanying  symptoms  of  stupor,  resulting  apparently  from  the 
direct  pressure  of  the  fragments  upon  the  brain,  it  is  sometimes  thought 
expedient  to  lift  the  depressed  portion  of  bone  and  relieve,  if  possible, 
Hie  symptoms  of  compression.  This  operation  is  effected  by  enlarging 
the  wound  of  the  scalp.  A  crucial  incision — two  lines  crossing  each 
other  at  right  angles — is  made  over  and  directly  to  the  depressed  bone, 
and  the  four  corners  are  dissected  up  as  in  plate  21,  fig.  2,  a  a  a  ", 
which  exposes  the  skull  covered  by  periosteum.  An  incision  is  made 
into  this  membrane,  which  is  so  intimately  attached  to  the  bone  that  it 
must  be  scraped  off  from  a  sufficient  space  to  allow  the  application  of 
the  trephine.  This  instrument  is  a  circular  saw,  a  section  of  a  cylinder 
with  the  saw-teeth  arranged  upon  its  free  end,  working  upon  a,  central 
movable  pivot.  An  improvement,  which  consists  in  making  the  body 
of  the  instrument  a  truncated  cone,  with  teeth  npon  the  side  as  well  as 
upon  the  end,  has  been  attributed  to  Mr.  Gait,  of  Virginia  ;  but  draw- 
ings strikingly  similar  can  be  found  in  Heistcr's  Surgery,  published  in 
London,  1757,  which  Heister  in  the  text  speaks  of  as  "the  trephine 
which  I  use."  The  advantages  which  the  conical  trephine  possesses 
over  the  cylindrical  is.  that  the  pressure  in  cutting  is  borne  mostly 
upon  the  rim  of  the  skull  and  not  upon  the  fragment  which  is  being 
removed,  and  therefore  there  is  much  less  danger  of  wounding  tho 
membranes  and  brain. 

When  we  have  a  choice  in  the  position,  we  would  not  place  the  tre- 
phine over  the  anterior  inferior  angle  of  the  parietal  bone,  for  fear  of 
injuring  the  meningeal  arteries,  a  a  a  (plate  21,  fig.  1 ),  which  often  lio 
deeply  embedded  in  grooves  traced  upon  the  inner  face  of  this  bono  ;  nor 
over  the  lateral  and  longitudinal  sinuses,  which  arc  seen  in  the  same 
figure — c  d,  and  b  b  b. 

When  the  trephine  is  used  to  relieve  accumulations  of  fluid  within  the 
skull,  it  should  be  applied  directly  over  the  supposed  Beat  of  the  fluid. 
When  used  to  assist  in  the  elevation  and  restoration  of  depressed  bone, 

the  point  or  axis  of  the  saw  is  placid  upon  the  contiguous  edge  of  un- 
injured bone,  so  that  the  circular  saw,  in  its  rotary  movements,  will  cut 
out  a  small  segment  of  the  depressed  bone  and  a  much  larger  picco  of 

the  healthy  skull. 

Tin-  e  urgeon,  holding  the  handle  of  the  instrument  firmly,  as  in  plate  21 , 
Bg.  2,  with  i  i."  laced  upon  the  crown  of  the  instrument  to  steady 

it,  and  point  or  axis  protruding  a  twelfth  of  an  inch,  commencei  by  rotating 


BTDROCJ 

ft  ui'li  it  the  instrument,  so  as  to  bore  into  the  skull  and  bury 
the  pivot     Upon  this  as  an  axi  eth  revolve,  cuttii 

the  bone.    When  this  gro  ently  deep  to  oonfino  the  instrument 

and  allow  it  t"  oontinae  its  rotatory  motion  without  the  nse  of  the  nxis, 
the  pivot  la  drawn  within  the  oyllnder,  10  that  .ill  injury  to  the  mens* 
brane  by  this  perforating  point  "ill  be  avoided.     After  cutting 
into  the  skull,  the  bottom  of  the  groove  should  be  examined  by  ■  probe 

or  (piili,  to  determine  which  porti i  the  hone  bas  been  cut  through* 

The  sensation  Imparted  through  the  quill  can  readily  detect  the  hardj 
nndlvi  led  bom  from  t li c-  mambraoes  beyond  the  out  portion.     When  the 
trephine  is  reapplied,  pressure  must  he  only  made  by  the  rim  ol  I 
upon  thai  portion  of  the  bone  not  yel  out  through.     When  it  Is  found  that 
nearly  the  entire  crown  bas  been  eut  through,  the  trephine  is  removed  and 

the  end  of  a  lever  placed  in  the  groove,  I  which  the  round 

piece  of  bone  is  lifted  from  it.-  position.     Through  the  opening  I 
end  of  the  lever  can  be  easily  applied  beneath  tl 
hear  in;:  down  upon  the  long  arm  of  the  lever,  using  the  rim  of  th< 
ing  in  the  uninjured  bone  as  a  fulcrum,  the  depressed  fragmei 
priced  ap  into  place— plate  SI,  li^r.   I.    Should  largi  found 

quite  detached  they  should  be  rem<  as  they  will  die,  having 

had  their  nutrition  destroyed.  Should  the  dura  mater  and  brain  be- 
neath be  in  a  healthy  condition,  the  dura  mater  will  retain  its  natural 
level,  the  pulsating  of  the  brain  being  clearly  seen.  If  the  operation 
has  been  performed  to  relieve  the  afieots  of  pressure  produced  by  the 
accumulation  nf  fluid  under  this  membrane,  it  will  at  once  rise  up.  flll- 

■    trephine  hole,  when  the  poind  pice  ■  .1  bone  is  removed,  and  no 
pulsation  will  he  transmitted    through    it.      Under   these   circumstances 

it  will  he  necessary  to  inolse  the  dura  mater,  to  allow  the  pent  up  fluids 
compressing  the  brain  to  aaoape.     w  hen  the  operation  ha-  been  pom? 
pleted,  the  Baps  in  the  scalp  are  olosed  bj  suture,  and  cold  water  dress- 
piled. 


in  !>]:■><  BLE 


Hydrocele,  s  di  tmmon  in  tho  army,  < n°i8ts  in  an  accu- 

mulation of  fluid  in  the  scrotum,  being  contained  in  the  cavity  of  the 
tunica  vaginalis.  Tho  enlargement  formed  of  the  scrotum  is  round  or 
oval,  uniformly  hard,  yet    ah.  -inc.    fluctuation.      It 

iroin  hernia  by  being  < lined  altogether  to  Ve  soro* 

turn,  the  cord  where  it  passei  into  tin-  abdomen  being  soft  and  of  Its 
usual  size.     As  all  hern]  |  m  the  abdomen,  SUOO  tumors  always 

gradually  •> me  •   must 


HYDROCELE.  521 

always  hare  thoir  enlarged,  stout  neelc  loading  directly  into  tho  ab- 
domen. 

Hydrocele  is  distinguished  from  diseases  of  tho  body  of  tho  testicle,  by 
tho  latter  being  irregularly  hard  and  inelastic,  also  feeling  hoavy  when 
the  mass  of  the  swelling  is  supported  in  tho  hand.  In  hydrocele  tho  skin 
is  seldom  involved,  while  in  diseased  and  enlarged  testicles  the  skin  is 
usually  red  and  quite  sensitive.  Tests,  to  detect  fluctuation  in  painless, 
uniformly  enlarged  scrota,  in  which  tho  increase  in  size  has  been  slow, 
without  symptoms  of  inflammation,  I  have  found  best  applied  as  follows: 
I  usually  seize  the  body  of  the  swelling  between  the  index  finger  and 
thumb  of  the  right  hand,  while  tho  upper  portion  of  tho  swelling  is  held 
firmly  between  the  index  finger  and  thumb  of  the  left  hand.  By  alter- 
nately squeezing  with  the  right  hand,  then  with  the  left,  the  fluid  dis- 
placed by  one  hand  will  be  felt  to  force  asunder  the  fingers  of  the  other. 
I  have  found  this  a  very  simple  and  successful  test  fur  hydrocele.  In 
the  posterior  portion  of  the  swelling  will  always  bo  felt  a  hard  mass, 
which  is  the  testicle.  The  tunica  vaginalis,  as  it  is  reflected  from  the 
scrotum  to  the  testicle  proper,  leaves  in  front  of  it  a  sac  in  which  the  se- 
rous fluid  collects.  As  it  accumulates  it  forces  the  testiclo  away  from  the 
anterior  wall  of  the  scrotum,  and  removes  the  dangers  of  injuring  tho 
testicle  during  the  operation  for  tapping  the  sac  and  drawing  off  the  fluid 
accumulation. 

The  method  for  tapping  a  hydrocele  is  as  follows :  The  left  hand  of 
the  surgeon  seizes  the  upper  portion  of  the  enlarged  scrotum,  grasp- 
ing (plate  22,  fig.  1)  the  entire  circumference  of  the  tumor,  forcing  the 
fluid  into  the  lower  portion  of  the  sac,  and  stretching  the  skin  of  the 
scrotum  over  the  tumor.  This  position,  by  forcing  the  fluid  between 
the  testicle  and  the  anterior  wall  of  the  sac,  renders  the  puncture  of  the 
testicle  impossible,  if  the  instrument  be  properly  directed.  With  a  small 
sharp  trocar  and  canula,  held  between  the  thumb  and  second  finger,  the 
handle  butting  against  the  base  of  the  thumb,  and  with  index  finger  upon 
the  stem,  guarding  the  depth  to  which  the  instrument  should  be.  thrust 
into  tho  scrotum,  the  point  of  tho  trocar  is  placed  upon  that  portion  of  tho 
anterior  and  inferior  portion  of  the  tumor  devoid  of  large  veins,  and,  by 
a  forward  and  sudden  movement  of  the  wrist,  the  instrument  is  thrust 
obliquely  backward  and  upward,  in  a  direction  somewhat  oblique  to  the 
long  axis  of  the  swelling.  As  soon  as  the  surgeon  feels  the  resistance 
r  that  the  point  of  the  trocar  has  passed  through  the  walls  of  the 
scrotum  and  lies  in  the  cavity  >•!  the  tunica  vaginalis,  he  draws  out  tho 
trocar,  while  the  canula  is  pushed  forward  well  into  the  cavity.  As 
soon  a»  the  trocar  is  drawn  oul  :i  clear  serum  escapee  in  n  stream,  the 
cavity  is  rapidly  emptied,  and  the  swelling  disappears. 

This  tapping  of  tho  sac  is  only  a  palliative  remedy:  for,  although  tho 
fluid  may  not  rcaccumulate,  it  most  frequently  ted,   Hid  after 

Rb 


522  \  MUCOCELE. 

a  few  months  the  scrotum  will  attain  its  former  enlarged  size.  This 
tupping  can  be  renewed  from  time  to  time,  without  inconvenience  or 
danger.  No  treatment  is  necessary  after  this  puncture  the  patient 
usually  attending  to  his  ordinary  duties,  without  laying  up  an  hour. 
The  use  of  a  suspensory  bag  is  the  onlj'  clement  of  treatment  neces- 
sary. Where  the  patient  desires  security  from  the  recurrence  of  the  ac- 
cumulation, he  can  obtain  it  by  the  injecting  of  the  tincture  of  iodine 
into  the  sac,  wbich  so  inflames  the  lining  surface  of  the  sac  as  to  cause 
it's  two  opposing  surfaces  to  adhere  to  each  other,  and  by  thus  obliterat- 
ing the  cavity  prevent  any  further  secretion.  In  some  instances, 
although  this  adhesion  does  not  occur,  the  lining  surface  has  its  func- 
tions so  modified  that  it  ceases  to  secrete  this  excess  of  fluid.  A  long 
list  of  irritating  substances  have,  from  time  to  time,  been  used  as  an  in- 
jection. The  profession  at  large  have  now  adopted  the  tincture  of 
iodine,  as  it  gives  the  largest  number  of  cures,  accompanied  with  the 
smallest  number  of  accidents.  After  the  fluid  has  been  drawn  off,  one 
drachm  of  tincture  of  iodine,  diluted  with  two  drachms  of  water,  is  in- 
jocted  through  the  canula  into  the  sac,  and  is  left  in,  the  instrument 
being  withdrawn.  After  the  injection  pain  is  soon  experienced,  of  a 
very  sickening  and  painful  character,  extending  in  the  direction  of  the 
cord  to  the  origin  of  the  spermatic  nerves  in  the  spine,  which  may  in- 
crease to  such  intensity  as  to  require  the  free  use  of  morphine.  In- 
flammation attacks  the  lining  membrane  of  the  sac,  extending  to  the  skin 
of  the  scrotum — the  tumor  becoming,  in  forty-eight  hours,  red,  hot,  swol- 
len, and  painful.  As  the  sac  rapidly  redistends  with  fluid,  it  is  the  prac- 
tice of  many  surgeons  to  puncture  at  the  end  of  the  third  or  fourth  day, 
and  draw  off  the  accumulation,  when  the  inflammation,  under  the  cold 
water  troatment,  subsides,  and  the  scrotum  in  time  nearly  resumes  its 
healthy  dimensions.  As  the  inflammation  in  the  tunica  vaginalis  has 
thickened  both  the  testicular  and  scrotal  membranes,  there  remains  for 
a  long  time  apparently  a  slight  enlargement  of  the  testicles.  If  the 
fluid  bo  not  drawn  off,  absorption  gradually  reduces  the  tumor,  and  the 
final  result  is  equally  satisfactory,  although  the  cure  is  more  protracted. 
After  the  disappearance  of  the  more  acute  inflammatory  symptoms, 
painting  the  scrotum  with  the  tincture  of  iodine  will  hasten  the  ab- 
sorption of  the  fluid. 


VARICOCELE. 


Varicocele  is  an  affection  very  frequently  encountered  by  a  military 
surgeon,  and  one  for  which  too  many  efficient  men  are  put  upon  light 
duty,  or  discharged  from  the  army.     It  consists  of  a  relaxation  and  eu- 


VARICOCELE.  523 

largoment  of  the  spermatic  veins,  a  varicose  condition  in  which  the 
vessels  become  much  enlarged  and  tortuous.  The  left  spermatic  veins 
are  far  more  frequently  affected  than  the  right,  which  is  aooounted  for 
by  fecal  accumulations  in  the  sygmoid  flexure  of  the  colon  oomprcssing 
the  vessels,  and  preventing  the  ready  return  of  blood  from  them;  and 
also  to  tho  absence  of  a  valvular  formation  at  the  extremity  of  the  left 
spermatic  vein,  where  it  empties  into  the  vena  cava,  ami  which  permits 
regurgitation  of  blood.  The  rarity  of  varicocele  upon  tho  right  sido 
is  accounted  for  by  the  presence  of  this  valve  at  the  termination  of  tho 
vein. 

Varicocele  is  recognized  by  an  enlargement  of  the  spermatic  cord, 
extending  to  the  scrotum,  and  varying  at  times  in  size.  When  in  the 
recumbent  posture,  and  at  rest,  the  swelling  nearly  disappears.  In  this 
respect  it  siinilatcs  hernia.  If  pressure  be  made  upon  the  upper  part  of 
tho  cord,  and  the  patient  resume  the  erect  position,  the  veins  accumu- 
late blood,  which  the  pressure  prevents  from  returning  into  tho  circu- 
lation, and  the  tumor  reappears.  In  this  respect  it  differs  from  hernia, 
which  could  not  reappear  as  long  as  the  pressure  is  continued,  as  tho 
linger  prevents  the  bowel  from  protruding  through  the  abdominal  open- 
ing. When  the  cord  is  felt,  the  sensation  of  a  large  number  of  soft 
vessels  is  transmitted,  resembling  earth  worms — plate  22,  fig.  6.  The 
tortuous  condition  of  the  veins  is  often  easily  recognized  on  the  surface 
of  the  scrotum.  Under  exercise  the  swelling  enlarges,  accompanied 
by  a  sensation  of  weight,  and  often  of  acute  pain  of  a  neuralgic  char- 
acter, extending  to  the  groin  and  loins.  This  pain  is  often  so  severe  as 
to  prevent  the  patient  from  walking  or  riding,  and  therefore  attending 
to  active  service. 

The  treatment  of  varicocele  will  depend  upon  its  extent.  In  mild 
supporting  the  testicle  in  a  suspensory  bag,  and  thus  relieving 
all  traction  upon  the  cord,  is  found  a  sufficiently  palliative  remedy.  In 
cases  where  tho  vessels  are  tortuous,  and  in  which  the  suspensory  bag 
does  not  remove  the  symptoms  to  such  an  extent  as  to  permit  the 
patient  to  attend  to  his  daily  duties,  an  operation  is  called  for,  which 
has  for  its  object  tho  obliteration  of  the  enlarged  veins  by  ligation. 
Plate  22  gives  three  methods  for  effecting  this  result.  In  fig.  2  an 
incision  is  made  from  one  and  a  half  to  two  inches  in  length,  parallel 
with  and  directly  over  the  spermatic  oord,  carefully  dividing  upon  a 
grooved  director  each  layer  of  cellular  tissue  uutil  the  elements  of  tho 
cord  are  clearly  exposed.  By  feeling  the  mass  of  enlarged  vessels, 
one  will  be  felt  much  harder  than  the  rest.  This  is  the  vas  deferens,  or 
excretory  duct  of  the  testicle,  and  is  the  only  element  of  the  cord  which 
must  Ik-  omitted  in  tying  the  vessels.  This  hard  tube  being  carefully 
avoided  (plate  22,  tig.  2),  all  of  the  remaining  vessels  are  surrounded  by 
a  ligature,  which,  in   time,   will  cause   their  obliteration.     As  the  spcr- 


524  VARICOCELE. 

niatic  nerves  are  always  included  in  the  noose  of  the  ligature,  tho  pain 
of  the  operatiou  is  very  severe. 

The  vessels  can  be  as  readily  secured  without  an  incision  by  passing 
a  pin  behind  them,  and  twisting  a  ligature  in  figure  of  8  over  the  ends 
of  the  pin.  The  cord  being  seized  between  the  thumb  and  index 
finger,  its  elements  arc  felt,  and  the  hard  cord  or  vas  deferens,  which  is 
easily  distinguished,  is  separated  from  the  soft  vessels  and  pushed 
backward.  The  remaining  vessels  are  drawn  as  far  forward  as  pos- 
sible, stretching  the  skin  over  them,  when  a  piu  is  thrust  through  tho 
skin,  from  within  outward,  passing  behind  the  mass,  and  its  point  reap- 
pears again  through  the  skin  upon  the  opposite  side.  A  thread  is  then 
firmly  twisted  around  the  protruding  extremities  of  the  pin,  which 
causes  sufficient  pressure  upon  the  vessels  to  effect  their  permanent 
obliteration  in  six  or  eight  days.  Plate  22,  fig.  fi,  shows  the  position  of 
the  pin  behind  the  tortuous  veins;  and  in  fig.  7  is  exhibited  the  appear- 
ance of  the  pin  with  thread  firmly  twisted  in  figure  of  8  around  the 
protruding  extremities.  The  point  of  the  pin  should  be  cut  off  after 
the  operation  is  completed,  to  avoid  its  pricking  the  surrounding  soft 
parts.     The  pin  is  withdrawn  at  the  end  of  the  sixth  or  eighth  day. 

A  second  method  for  obliterating  these  vessels  is  by  the  use  of  a  sub- 
cutaneous ligature,  applied  as  shown  in  plate  22,  fig's  3,  4,  and  5.  In 
fig.  4  is  seen  two  doubled  threads,  with  looped  extremities,  each  double 
thread  passing  through  the  loop  of  the  other.  When  they  are  firmly 
drawn,  as  in  fig.  5,  it  is  seen  how  they  compress  firmly  the  vessels. 
The  mode  of  application  is  as  follows  :  Both  ends  of  a  piece  of  strong 
flax  or  silk  thread  are  passed  through  the  eye  of  a  needle,  which  leaves 
a  loop  at  one  extremity  of  the  double  thread.  The  cord  being  seized 
between  the  thumb  and  index  finger  of  the  surgeon,  is  drawn  forward, 
the  hard  cord  of  vas  deferens  distinguished  and  pushed  behind  and 
away  from  tho  mass,  which  is  drawn  forward.  The  needle  is  then  in- 
serted behind  the  fingers,  and  drawn  through  upon  the  opposite  side,  so 
as  to  have  in  front  of  the  thread  all  of  the  vessels  of  the  cord  oxcept 
the  vas  deferens,  which  was  pushed  out  of  tho  way.  Fig.  3  gives  the 
position  of  the  double  ligature  and  loop.  A  second  needle  is  now 
taken,  with  a  similar  ligature,  and  the  skin  of  the  scrotum  over  the 
cord  alone  drawn  forward.  The  point  of  the  needle  is  entered  through 
the  orifice  from  which  the  first  one  escaped,  and  passing  superficially 
under  the  skin  and  over  the  vessels,  escapes  out  of  the  first  puncture, 
so  that  a  loop  remains  on  each  side  of  the  cord.  The  corresponding 
ends  of  the  threads  are  passed  through  tha  loops  (fig.  4),  and  the 
threads  drawn  upon  as  in  fig.  5,  when  the  loops  at  once  bury  themselves 
in  the  punctures  and  compress  the  vessels.  When  firmly  drawn,  they 
should  be  tied  over  the  cords.  A  single  ligaturo  can  be  applied  in  the 
same  way,  and  will  give  better  results.     First  pass  the  needle,  armed 


FISTULA   IN    ANO.  525 

with  a  single  thread,  behind  the  vessels,  and,  drawing  tho  skiu  forward, 
pass  it  back  through  the  sumo  openings  in  front  of  tho  vessels,  and  tie 
as  usual.  The  knot  at  once  buries  itself  in  tho  puncture,  aud  disappears 
from  view. 


FISTULA  IN  ANO. 

Fistula  in  nno  is  a  very  common  affection,  particularly  in  the  cavalry 
arm  of  the  service.  It  is  caused  by  the  formation  of  abscesses  in  the  vicin- 
ity of  the  rectum,  which,  after  discharging  their  purulent  contents  either 
into  the  rectum  or  externally  upon  tho  buttock  or  porinaium,  refuse  to 
heal.  They  become  chronic,  contracted,  tortuous  passages,  called  fistula;, 
from  which  a  inuco-purulent  discharge  continues,  much  to  the  annoyance 
of  the  patient  so  afflicted.  There  are  three  forms  in  which  this  disease 
shows  itself.  Plate  23,  fig's  1  and  2,  indicate  varieties  of  incomplete  fis- 
tulas. In  fig.  1  the  fistulous  passage  passes  from  a  cul  de  sac  and  empties 
its  secretion  into  the  rectum,  r,  just  above  the  internal  sphincter,  leaving 
no  opening  upon  the  outer  surface  through  which  the  purulent  contents 
of  tho  fistula  can  be  discharged  externally.  In  this  case  pus  would  be 
discharged  per  an  urn  during  defecation.  In  fig.  2  is  seen  a  much  more 
common  variety  of  incomplete  fistula — b,  the  tortuous  blind  cul  de  sac, 
with  its  neck,  o,  ending  externally  upon  the  inner  face  of  the  buttock. 
The  cavity  having  no  communication  with  the  rectum,  tho  purulent  dis- 
charge would  uot  be  thrown  into  this  cavity,  but  would  be  poured  out 
continually  upon  the  external  surface  within  the  fold  of  the  buttock.  Fig. 
3  represents  also  a  common  variety  called  a  complete  fistula  in  ano,  inas- 
much as  the  fistula,  b  b,  has  an  inner  connection  with  the  rectum  at  a, 
and  also  an  external  orifice  upon  the  buttock  at/.  The  contents  of  this 
secreting  passage  can  either  be  emptied  into  the  bowel  or  be  poured  upon 
the  outer  surface  of  the  anal  region.  Owing  to  the  free  communication 
between  the  cavity  of  the  rectum  and  tho  external  surface,  small  parti- 
cles of  fecal  matter  escape  through  the  fistula,  giving  an  offensive  odor 
to  the  secretion.  Gases  also  escape  from  the  rectum  by  this  passage. 
The  opening  into  the  rectum  is  usually  found  immediately  above  tho 
sphincter  muscle,  from  one  to  one  and  a  half  inches  from  tho  outer  sur- 
face of  the  anus;  rarely  over  this  depth.  When  wo  hear  of  cases  in 
which  the  passage  of  a  probe  oxtended  for  three  and  four  inches  along- 
side of  tho  bowel  it  can  be  readily  understood,  for  the  previously  existing 
abscess  may  have  been  a  large  one,  and  have  dissected  the  tissues  for  a 
considerable  distance;  but  when  we  hear  of  an  opening  in  tho  bowel 
from  three  to  four  inches  from  the  orifice,  it  means  that  the  operator, 
in  passing  the  probe,  had  missed  the  lower  opening  in  the  bowel  just 


I  int"  the  bowel,  m  it  only  by  «  thin  mu- 

cus membrane,  bad  (breed  the.  probe  tbrongb  it.  making  a  second  and 
artificial  opening  from  tin-  extremity  ol  tl  ae  i > 1 1 - •  the  rectum. 

■  .  irbetheT  complete  "i-  othern  ise,  usually  run  up 
leaving  only  the  thickness  of  the  muc 

camlning  a  patient  suspected  of  having  an  anal  Batuln,  I 

Che  buttock  draw  i 
by  mi  assistant,  or  the  buttock  being  drawn  aside  with  the  left  hand  "f 
i  - 1 1 1 ; i  II  papule  or  conical  elevation,  resembling 
a  granulation,  in  the  centre  of  whiob  "ill  be  found  a  small  orifice.     Bj 
pressure  upon  the  buttock  this  orifice  is  by  the  appearance 

of  a  drop  of  pus  Bqueesed  from  the  Interior  of  the  fistula  It'  the  bulb 
of  ;i  silver  probe  is  introduced  into  this  orifice  and  very  flight  pi 
ii  . ,],  it  will  find  its  own  way  tbrongb  the  fistula,  and  will  usually  take 
up  ••!  direction  inward  and  apward  toward  the  bowel.  Should  it  be  neo- 
i  Mary  the  probe  should  be  slightly  bent,  t"  enable  it  to  follow  mora 
readily  the  irregularities  of  the  pa  thould  b<  d 

amination,  and  when  1.1 1  is  drawn   it   ind 

rongh  and  painfnl  exploration.  If  the  index  finger  be  passed  into  the 
rectum  above  the  sphincter  muscle  of  the  anus,  the  end  <d"  the  probe 
oan  be  readily  fell  separated  fr<  m  the  finger  bj  a  thin  mucus  mem- 
brane, which  gives  the  impression  of  the  bulb  being  covered  by  a  thin 
film.  Often  the  probe  wtll  find  its  way  through  an  opening  in  this  ut- 
tenuated  mucus  membrane,  and  pass  into  the  bowel  in  contact  with  tho 
ben  ihc  mil  •!<  xii, ■  continues  apward  along  the  bowel  for 
r  three  inches. 

Dstulse  show  so  little  disposition  to  heal  by  the  usi 

or  local  applications,  thai  no  other  treatment  is  worth}  of isideration 

but  an  operation  whioh  bai  foi  its  objeet  the  radical  cure,     Bxp< 
shows  that  the  anatomy  of  the  parte  bas  muoh  to  do  with  the  difficulty 
ol  closing  up  these  secreting   |  bief  obstacle  to  healing 

to  reside  in  the  continued  action  of  the  Bphincter  muscle  of  tho 
anus,  whioh,  by  keeping  the  wall.- of  the  abscess  in  constant  motion, 
draw  the  opposing  sides  away  from  each  other  and  prevent  aniot 
perienoe  Bbows  thai  unless  the  sphinoler  muscle  is  divided,  a  cure  of 
rectal  fistulas  is  nearly  Impossible,  and  also  that  there  is  never  a  neoes* 
Bity  for  cutting  the  bowel  above  the  sphincter  musole.  Winn  Burgeons 
report  oaaas  in  which  an  incision  i-ur  inobea  deep  was  made  through 
the  bowel,  it  is  an  indication  of  hold  and  dangerous  surgery  from  ig- 
norai 
The  mode  of  procedure  in  operating  for  fistula  in  ano  is  as  follows: 


FISTULA    IN    ANO.  527 

Tho  bowels  having  been  well  emptied  by  a  purgative  dose,  the  patient 
lying  upon  his  side,  us  in  plate  23,  fig.  6,  and  under  tho  influence  of 
chloroform,  a  small  silver  grooved  director,  terminating  in  a  probe,  has 
its  probe  extremity  entered  into  the  fistula,  and  passing  upward  through 
the  sinus  toward  tho  bowel,  is  fell  by  the  index  finger  of  the  left  hand 
passed  into  the  anus.  As  soon  as  the  finger  feels  that  the  probe  reaches 
the  mucus  membrane  of  the  rectum,  immediately  above  the  internal 
sphincter,  and  about  one  inch  from  the  external  surface  of  the  anus,  an 
effort  is  made  to  find  B  passage  into  the  bowel.  Should  none  he  found, 
tho  surgeon  turns  the  end  of  the  probe  against  the  thin  mucus  mem- 
brane just  above  the  sphincter,  "and  without  hesitation  forces  a  pas- 
sage into  the  rectal  cavity,  thus  rendering  the  sinus  a  complete  fistula. 
The  probe  is  now  thrust  forward  and  upward  sufficiently  to  onablo  the 
bulb  of  the  index  finger  to  hook  the  end  of  the  probe,  as  in  fig.  4,  and, 
drawing  it  downward  and  outward,  draw  its  extremity  through  the  rec- 
tum and  anus  until  it  rests  upon  the  opposite  but  lock,  both  ends  of  tho 
probe,  being  risible,  the  grooved  portion  remaining  in  the  fistula — fig. 
5.  The  sphincter  muscle,  the  enemy  to  the  healing  of  the  fistula,  is 
now  clearly  on  the  outside  of  the  probe.  The  blade  of  a  sharp-pointed 
bistoury  is  now  run  through  the  groove  in  the  director,  and  in  cutting 
its  way  out  cuts  out  the  probe  and  divides  completely  the  sphincter 
muscle.  As  soon  as  the  probe  is  cut  out  blood  wells  up  freely  from  the 
wound,  as  the  hemorrhoidal  arteries  ramifying  around  the  anus  are 
divided  in  the  incision.  A  sponge  is  thrust  into  the  wound  to  dry  the 
surface  of  the  incision,  while  the  surgeon  saturates  a  piece  of  soft  lint 
with  the  liquid  persulphate  of  iron.  Removing  the  Sponge,  the  lint  is 
i  lmi- 1  to  the  bottom  of  the  wound,  a  compress  applied,  and  secured  by  a 
T  bandage.  One  band  passes  around  the  waist,  the  other  passes  be- 
livoii  the  buttocks,  around  the  peiinseum,  with  the  anterior  portion  of 
the  band  slit  so  as  to  allow  one  strip  to  pass  on  each  side  of  the  scro- 
tum and  across  each  groin,  to  be  secured  to  the  abdominal  band.  Opium 
is  freely  given  to  allay  pain  and  to  keep  tin'  bowelfl  quiet.  When  sup- 
puration is  established,  which  is  usually  at  the  end  of  the  second  or 
third  day.  the  dressings  are  removed,  which  will  expose  a  clean,  granu- 
lating wound.  A  daily  dressing  of  a  little  simple  cerate  upon  a  soft 
doth,  secured  in  place  by  the  T  bandage,  i.-  all  the  dressing  required. 
;iiis  simple  treatment  the  wound  will  granulate  from  the  bottom 
and  sides,  and  gradually  becoming  more  superficial,  will,  in  the  course 
of  two  or  three  w<  i  mpletely  cicatrised — a  radical  cure  of  the 

annoying  fistula.  'I  be  upper  portion  of  the  ml  ih  toe,  above  the  point 
where  the  probe  was  forced  into  the  tectum,  usually  heals  -itnultanc- 
onsly  « itli  the  res!  of  the  sit  u>.  and  gh  <  -  no  trouble. 

binary  ni'  tbod  of  dressing  Dstulse  after  an  o]  I  be  ap- 

lint,  which  is  forced  up  the  rectum  daily: 


528  FISTULA    IN    ANO. 

•  depth  as  the  bottom  of  the  wound  fill?  up  with  granulations, 
until  the  dressing  becomes  a  superficial  one.  The  object  of  this  treat- 
ment is  based  upon  tin-  desire  t"  prevent  tin'  wound  healing  by  quiok 

union.  The  incision  being  performed  by  ;i  ibarp  instrument,  leaves 
two  nicely  cut  surfaces  in  apposition  t"  each  other,  which  would  unite, 
together  in  twenty-four  hours,  leaving  the  fistulous  passage  lined  by  its 
hard,  secreting  membrane,  unohlitcrated.  Tbo  consolidation  of  tin- 
sinus  can  only  be  secured  by  keeping  the  lips  of  the  wound  asunder, 
so  as  to  force  granulations  to  form  along  the  lining  membrane  of  the 
fistula,  and  thus  force  the  wound  to  heal  from  the  very  bottom. 

Although  the  daily  application  of  the  tent  of  lint,  thrust  between  the 
lips  of  the  wound,  prevents  any  union,  it  is  a  very  painful  operation — 
even  more  so  than  the  cutting — as  it  forces  a  large  roll  of  lint  against 
a  very  sensitive,  inflamed  surface:  it  is  also  a  very  troublesome  appli- 
cation. The  use  of  the  persulphate  of  iron,  either  upon  a  camel's  hair 
brush  or  a  soft  piece  of  lint,  is  in  every  way  a  preferable  remedy. 
When  the  entire  surface  of  the  wound  is  carefully  swabbed  with  this 
stroug  fluid,  its  immediate  action  is  to  form  a  hard,  crusted  clot  of 
blood  over  the  surface,  which  checks  the  bleeding,  and  placing  a  foreign 
body  between  every  portion  of  the  opposing  surfaces  precludes  tin-  pos- 
sibility of  adhesion  by  the  first  intention.  Again,  the  application  of  the 
persulphate  or  perchloride  of  iron  acts  as  a  cau.-iie.  produoing  a  super- 
ficial Blongh  from  the  entire  surface  of  the  wound,  including  the  pyo- 
genic membrane  with  which  the  fistula  was  lined,  which,  in  itself,  would 
prevent  any  quick  union.  It,  inoreo\er.  stimulates  the  surface  iu  such 
a  way  as  to  cause  the  rapid  formation  of  granulations;  and  theu  has 
the  very  decided  advantage  over  all  other  applications  that  no  further 
dressing  is  required. 

Surgeons  who  use  the  greased  lint  tent  lay  grea'  Btress  upon  the  daily 
dressing,  as  a  very  important  element  in  the  successful  treatment. 
With  the  thorough  application  of  the  persulphate  of  iron  I  have  no 

further  fear  for  the  patient,  nor  oven  is  it  necessary  for  the  BurgOOfl  to 
see  him  again.  Should  he  have  come  from  a  distance  to  bo  operated 
upon,  he  can  return  to  his  friends  the  same  day,  a  few  hours  after  the 
operation  has  been  performed,  the  Burgeon  giving  the  assurance,  which 
experience  with  this  remedy  will  permit  him  to  do,  that  the  case  will 
now  cure  itself  without  further  treatment.  I  have  used  this  remedy  for 
ten  years,  in  every  instance  with  success.  It  is  a  perfect  method,  which 
leaves  nothing  to  be  desired.  The  case  is  a  very  rare  one  which  require! 
the  patient  to  keep  bis  room  more  than  twenty- four  hours. 

The  use  of  opium  is  kept  np  for  four  or  five  days,  when  the  bowels  are 
emptied  by  a  dose  of  Castor  oil,  citrate  of  magnesia,  or  any  simple  medi- 
cine, mild  in  its  action,  which  will  produce  fluid  evacuations :  after  which 
tbo  case  is  left  to  nature.     Although  the  sphincter  is  or  nkould  /"■  divided 


FISTULA    IN    ANO.  529 

completely  in  every  case,  no  fear  should  be  felt  that  the  muscle  will  not 
unite  again,  and  control  over  the  contents  of  the  bowel  be  resumed.  It 
may  bo,  however,  one  or  two  weeks  before  the  patient  will  have  the 
perfect  control  of  the  sphincter  muscle,  but  it  will  assuredly  be  regained 
in  every  case  in  which  the  operation  has  been  properly  performed,  as 
directed  above,  and  where  the  bowel  has  not  been  ignorantly  divided  to 
too  great  a  depth. 

A  ligature  passed  through  the  fistula  and  bowel,  with  the  intention 
of  cutting  slowly  and  very  painfully  through  the  same  structures  which 
the  knife  divides,  is  a  remedy  extensively  used  by  itinerant  specialists, 
who  take  advantage  of  the  suffering  community  by  depicting  the  hor- 
rors of  the  knife  to  nervous,  timid  patients,  and  extolling  the  certain 
success  of  a  simple  thread.  This  application  will,  at  times,  cure  fistula 
in  ano,  but  always  at  the  expense  of  much  suffering.  The  ecrascur,  or 
more  rapid  ligature,  is  troublesome  of  application,  and  possesses  no 
advantage. 


Ss 


Plate  1. 

Fig.  1. — A  Confederate  army  litter  for  transporting  wounded  men 
To  secure  the  heavy  duck-cloth  or  sacking  to  the  frame,  n  ^r'"-\  e  three- 
quarters  of  an  inch  wide  and  foe-eighths  of  an  inch  deep  u  out  out  in 
the  length  of  the  frame.  The  cloth  is  tacki-d  in  this,  and  Beoured  by  a 
lath  which  fits  accurately  the  groove,  and  which  is  nailed  in,  covering 
the  cloth.  The  tension  upon  the  cloth  is  not  borne  by  the  tacks,  but  is 
uniformly  supported  by  the  entire  lath,  and  therefore  never  rips  off. 

fi,h  2. — A  Confederate  four-wheeled  field  ambulance  wagon.  In 
the  Confederate  army  there  are  two  kinds  of  ambulance  wagons — one 
with  two  wheels,  and  the  one  represented  in  the  figure.  The  four- 
wheeled  is  the  most  convenient,  and  is  the  one  in  general  use. 


FIG  4 


r     I     0  t 


r  i   c  a 


.  [Yot.<  L  CefTandly  CcJwnJh^S 


Platk  2. 

Fig.  1. — Vertical  section  of  a  finger,  showing  the  relations  of  the 
phalangeal  bones  with  the  soft  parts ;  also  the  relations  which  the  artic- 
ular surfaces  bear  to  the  natural  folds  on  the  palmar  surfaco  of  the 
finger. 

Fig.  2. — A  finger  flexed  to  show  that  the  articulating  surfaces  are 
not  to  be  found  at  the  apices  of  the  angles  which  the  bent  finger  makes. 

Fig.  3. — Amputation  of  a  finger  in  second  phalangeal  joint.  The 
position  of  the  finger  while  the  knifo  enters  between  the  articulating 
surfaces  on  tho  back  of  the  finger. 

Fig.  4  shows  the  horizontal  position  of  tho  knife  after  having  trav- 
ersed the  joint  from  behind. 

Fig.  5. — Flap  operation — shows  the  knife  transfixing  the  finger  at 
the  second  digital  fold,  so  as  to  make  the  palmar  flap,  a  b  c  marks 
the  form  and  size  of  the  flap,  or  the  line  in  which  the  knife  will  cut 
from  within  outward. 

Fig.  6. — Continuation  of  the  same  amputation.  Flap  turned  back — 
the  knife  placed  perpendicularly,  dividing  the  anterior  and  lateral  liga- 
ments, and  passing  into  the  joint. 

Fig.  7  exhibits  two  methods  of  amputating  an  entire  finger,  a  d  c 
b  shows  the  flap  after  the  oval  method,  the  palmar  incision  following 
tho  palmar  fold  at  the  web  of  the  finger ;  a  c  b  the  method  by  two  later- 
al flaps,  the  incision  cutting  across  the  palmar  digital  fold,  and  passing 
up  obliquely  in  the  palm  nearly  to  the  transverse  fold. 

Fig.  8. — Tho  hand,  with  relation  of  bones  and  joints  to  the  soft  parts. 
a  b  c,  showing  the  extent  and  direction  of  incisions  in  amputating  the 
thumb,  with  its  metacarpal  bone,  at  its  articulation  with  tho  trapezium. 

Fig.  9  shows  the  position  of  the  thumb,  and  also  how  the  knife  is 
held  while  the  point  of  the  blade  divides  the  ligaments,  and  opens  freely 
tho  joint. 

Fig.  10. — The  appearance  of  the  wound  and  hand  after  removal  of 
th«  thumb. 


Plate  3. 

Fig.  1  represent?  the  line  of  incision  for  amputating  the  little  finger 
with  metacarpal  bone.  A  similar  line,  traced  upon  the  back  of  tho 
hand,  defines  the  extent  of  the  flap. 

Fig.  2. — Position  in  which  the  hand  is  held  in  amputation  of  the  fin- 
gers, a  b  c  shows  the  line  of  incision  for  opening  the  metacarpopha- 
langeal joints  ;  after  traversing  which,  the  direction  of  tho  knife  is 
changed,  as  in  the  figure,  so  as  to  make  a  flap  from  the  palmar  surface. 

Fig,  3. — a  b  c  marks  out  the  extent  of  the  flap,  and  shows  the  rela- 
tion of  the  heads  of  the  metacarpal  bones  to  the  soft  parts. 

Fig.  4.— Anatomy  of  the  hand.  «,  carpal  extremity  of  ulna;  b,  ex- 
tremity of  radius  ;  c,  semilunar  bone  ;  d,  scaphoid  ;  <•.  cuneiform  :  /, 
unciform ;  g,  os  magnum  ;  h,  trapezoid  ;  i",  trapezium  ;  1,  2,  3,  4,  5,  heads 
of  metacarpal  bones  of  the  thumb  and  fingers. 

Fig.  5. — Amputation  of  the  four  lingers,  with  their  metacarpal  bones. 
a  b,  showing  the  carpo-metacarpal  articulation  between  the  trapezoid, 
os  magnum,  and  unciform  for  the  carpus,  and  the  four  metacarpal  bones 
of  the  fingers  ;  6  c,  the  line  of  incision  extending  through  the  muscu- 
lar septum,  between  the  thumb  and  index  finger. 

Fig.  6. — The  completion  of  the  amputation,  a  b  c,  showing  the  ex- 
tent of  the  flap  from  the  palmar  surface:  <•,  on  ■  level  with  the  unciform 
bone,  and  a,  near  the  root  of  tho  thumb,  Indicating  the  two  points 
through  which  the  palm  is  transfixed  in  cutting  out  the  flap,  a  b  c. 

Fig,  7  indicates  position  of  hand  and  lino  of  incision  in  amputa- 
tion at  tho  wrist-joint,  with  palmar  flap. 

Fig.  8  shows  the  flexed  position  of  the  hand,  and  also  the  position 
of  the  knife  while  opening  tho  radio-carpal  articulation  from  the  back 
of  the  wrist,  and  completing  the  operation  commenced  in  fig.  7. 


FIG  % 


F.ra/u  umiruy 


fcuu  S  Cegt—^i,  '        , 


Plate  4. 

Fig.  1. — Delineations  of  the  prominences  upon  the  heads  of  the 
bones  forming  the  elbow-joint.     A,  humerus  ;  B,  radius  ;   C,  ulna. 

Fig.  2.— Lateral  view  of  the  elbow-joint.  A,  humerus,  with  internal 
condyle  and  epitrochloea  ;  B,  he,ad  of  radius  concealed  by  C,  the  head 
of  ulna,  with  olecranon  and  coranoid  processes— showing  the  curved 
line  marking  out  the  articulating  surfaces  of  humerus  and  ulna. 

Fig.  3.— Anterior  view  of  the  elbow-joint.  A,  humerus  ;  B,  radius  ; 
C,  ulna,  with  line  of  articulating  surfaces  between  the  three  bones. 

Fig.  4.— The  outlines  of  the  bones  of  the  arm  and  forearm,  a  c,  the 
points  at  which  the  knife  transfixes  the  forearm,  and  a  b  c,  the  outline 
of  the  anterior  flap  for  covering  the  head  of  the  humerus  in  amputation 
at  the  elbow-joint. 

Fig.  b.—A  B  C,  the  flap  delineated  fig.  4,  turned  up,  so  as  to  ex- 
pose the  line  of  articulation  as  seen  in  fig.  3,  and  the  position  of  the 
knife  as  it  completes  the  section  of  the  skin  on  the  back  of  the  elbow- 
joint. 

Fig.  6. — Circular  amputation  at  the  elbow-joint,  a  a,  flap  of  skin 
dissected  up  and  turned  over  upon  the  arm  as  the  cuflF  to  a  coat-sleeve. 
The  edge  of  the  knife,  placed  behind  the  arm  and  looking  toward  the 
operator,  completing  the  section  of  the  retentive  ligaments. 

Fi'.h  7.— The  appearance  of  the  stump  after  the  amputation.  B,  the 
head  of  the  humerus,  covered  with  cartilage,  with  remains  of  the 
fibrous  capsule,  a,  the  position  of  the  brachial  artery  in  front  of  the 
bone. 


Plate  5. 

Fig.  2. — Circular  amputation  of  the  forearm,  the  position  of  the 
arm  to  be  operated  upon,  and  also  the  position  of  the  hands  of  the 
operator.  The  first  black  line  above  the  wrist  indicates  the  line  of 
circular  incision  through  the  skin ;  b,  flap  separated  from  the  cellular 
tissue,  and  turned  up,  cuff-like.  The  second  line  marks  the  root  of  the 
fold  of  skin,  turned  up,  and  is  the  litre  of  section  for  all  the  muscles 
down  to  the  bone.  The  distance  between  the  second  and  third  line 
indicates  the  width  of  the  turned-up  flap. 

Fiy.  1  shows  the  retractor,  a  piece  of  cloth  thrust  between  the  bones, 
and  drawn  backward,  to  protect  the  soft  parts  of  the  stump  from  bein^ 
injured  by  the  saw. 

Fiy.  3. —  Flap  amputation  of  the  forearm,  c  e  d  shows  the  anterior 
flap  cut  up  by  transfixion,  and  exposing  at  b  a  the  radial  and  ulna 
arteries  in  the  anterior  flap  ;  c  d  shows  the  points  at  which  the  knife  is 
again  thrust  through  the  arm  behind  the  bones,  so  as  to  complete  the 
severing  of  the  muscles  by  making  a  posterior  flap. 

fig,  4. — The  appearance  of  the  stump  after  amputation  of  the  fore- 
arm by  anterior  and  posterior  flaps;  c,  cut  end  of  radius;  d,  of  ulna: 
a,  position  of  the  ulna  artery ;  b,  radial  artery. 

fig,  5. — Circular  amputation  of  arm.  rc,  the  first  circle  made  through 
the  skin;  b,  second  incision  made  through  the  musoles  to  permit  of  free 
retraction;  c,  third  line  of  incision  to  the  bone,  dividing  all  soft  parts. 

Pig,  6. — Appearance  of  the  stump  after  circular  amputation  of  tho 
arm.  1,  Biceps  muscle  ;  2,  humerus;  a,  brachial  vessels  on  inner  side 
of  stump;  b,  superior  profunda  branch  of  brachial  artery. 

Fig.  7. — Outline  of  stump  after  amputation  by  internal  and  external 
flaps,  showing  position  of  the  bono  at  angle  of  flaps. 


f.    i 


r   i    g         7 


F       I       C.  I 


'10.  «. 


-&«x/i«  if  Caysve-u,  ^Zt^mhcb,  S.C 


Plate  6. 

Fig.  1  represents  the  scapulo-humeral  joint ;  6,  clavicle  attached  to  c, 
the  accromial  process  of  d,  the  scapula :  c,  the  head  of  the  humerus 
secured  to  the  glenoid  cavity  by  the  capsular  ligament. 

Fig.  2  shows  the  position  of  the  glenoid  cavity,  a,  in  relation  to  the 
coracoid  process,  c,  and  accromial  process,  6. 

Fig.  3  shows  the  position  of  the  bones  of  the  shoulder  in  relation 
to  the  soft  parts,  and  also  the  position  in  which  the  limb  is  held  by  the 
surgeon  while  he  commences  an  amputation  at  the  shoulder-joint  by 
external  and  internal  lateral  flaps — Lisfranc's  method.  The  point  of 
the  knife  outers  the  arm  from  behind  at  c,  corresponding  to  the  poste- 
rior of  the  axillary  space  or  border  of  the  latissimus  dorsi  muscle, 
passes  obliquely  upward,  grazing  the  head  of  the  humerus,  and  ap- 
pears at  a,  which  corresponds  to  an  interspace  between  the  coranoid 
arid  accromial  processes  of  the  scapula.  The  lino  a  b  c  marks  the  extent 
and  direction  of  the  flap. 

Wig.  4. — Cutting  the  internal  flap  in  Lisfranc's  amputation,  a  b  e, 
external  flap  raised ;  d,  head  of  the  humerus  freed  from  the  glenoid 
cavity,  with  capsule  divided.  The  knife  has  passed  through  the  joint 
to  the  inner  side  of  the  humerus,  and  is  now  cutting  out  the  inner  flap. 

Fig.  5. — Larrey's  method  of  disarticulating  at  the  shoulder-joint. 
a  c  b,  a  short  perpendicular  incision  upon  the  head  of  the  humerus ; 
c  d  and  c  c,  two  lateral  incisions  passing  obliquely  downward,  and 
dividing  all  the  muscles,  isolating  the  joint. 

Fig.  6. — a  bed  shows  the  outline  of  the  incision  when  the  arm  has 
been  removed  by  the  oval,  or  Larrey's  method ;  e,  the  glenoid  cavity, 
with  remnants  of  capsular  ligament ;  c,  axillary  or  brachial  vessels. 
The  completion  of  the  operation  of  fig.  5  is  seen  to  be  a  circular  incision 
passing  around  the  axillary  portion  of  tho  arm  on  a  level  with  the  infe- 
rior boundary  of  the  axillary  space. 


Plate  7. 

Fig.  1. — Bones  of  the  foot.  «.  inferior  extremity  of  tibia;  b,  inferior 
extremity  of  fibula;  <■,  articulating  face  of  astragalus:  d,  external 
prominence  of  os  calcis;  e,  scaphoid  ;  /,  cuboid;  y,  internal  cuneiform; 
h,  middle  cuneiform  ;  t,  external  cuneiform  ;  1,  2,  3,  4,  5,  the  metatarsal 
bones,  with  formation  of  tarso-metatarsal  articulation.  Upon  this 
figure  the  direction  of  all  the  articulating  surfaces  can  be  studied. 

Fig.  2. — Lateral  outline  of  the  bone*,  with  relation  to  the  soft  parts. 
a  d  c  b  traces  the  line  necessary  in  amputating  the  big  toe,  with  its 
metatarsal  bone. 

Fig.  3. — A  foot,  showing  the  appearance  of  the  flap,  abed,  after  an 
oval  amputation  of  the  big  toe;  e,  head  of  metatarsal  bone ;  / h  y  rep- 
resent an  amputation,  with  two  lateral  flaps. 

Fig.  4. — The  relation  of  the  bones  of  the  foot  with  the  soft  parts,  with 
transverse  lines  marking  the  various  dorsal  incisions  necessary  in  per- 
forming all  disarticulations  of  the  foot.  a  a,  the  line  of  dorsal  incision 
required  in  amputating  the  toes ;  b  b,  incision  in  the  tarso-metatarsal 
amputation,  or  Lisfranc's ;  c  c,  line  of  themedio-tarsal,  or  Chopart's  am- 
putation ;  d  d,  the  dorsal  incision  for  Syme's  or  Pirogoff's  amputation, 
viz  :  tibio-tarsal  amputation. 

Fig.  5. — a  b  c,  amputation  of  all  the  toes.  The  knife  has  passed 
through  the  joints  and  behind  the  phalangeal  bones  to  complete  the  flap 
from  the  sole  of  the  foot. 

Fig.  6. — Lisfranc's  amputation.  Dorsal  flap  dissected  up,  exposing 
the  line  of  articulations,  a,  the  head  of  the  second  metatarsal  bone, 
boxed  in  between  the  external  and  internal  cuneiform.  The  figure 
represents  the  mode  of  dividing  the  lateral  ligaments;  a  b  c,  the  curve 
which  the  knife  makes. 

Fig.  7. — All  the  tarso-metatarsal  joints  opened,  and  blade  of  knife 
passed  behind  metatarsal  bones  to  make  the  posterior  flap. 

Fig.  8. — The  completion  of  the  plantar  flap  in  Lisfranc's  amputa- 
tion. /,  the  anterior  portion  of  the  foot  drawn  upward ;  b,  the  plantar 
flap ;  d,  the  mode  of  holding  the  knife  in  rounding  off  the  end  of  the 
flap. 

Fig.  9. — Chopart's  amputation,  or  the  medio-tarsal,  showing  how  the 
foot  is  grasped  in  the  left  hand  of  the  surgeon,  and  depressed  while  the 
knife  opens  the  joint  formed  by  the  astragalus  and  os  calcis  posteriorly, 
and  the  scaphoid  and  cuboid  anteriorly;  a,  dorsal  vessels  of  the  foot. 

Fig.  10. — Chopart's  amputation  completed,  ad,  dorsal  vessels ;  e, 
plantar  vessels,  on  under  and  inner  side  of  flap;  a  b  c  d,  size  and  form 
of  fl;ip  fro  n  sole  of  foot. 


f    i    o         e 


Plate  8. 

Fig.  1. — Lateral  sketch  of  foot,  with  relative  position  of  the  bones. 
The  lines  traced  across  the  foot  showing  the  direction  of  the  plantar 
incisions  for  performing  the  various  disarticulations  upon  this  extrem- 
ity. This  figure  should  be  studied  in  connection  with  plate  7,  fig.  J. 
a  a.  a  a,  the  line  of  the  tarso-metatarsal  incision  in  Lisfranc's  oper- 
ation; b  b  b  b.  the  incisions  for  effecting  the  medio-tarsal  or  Cho- 
part's  amputation  :  c  c  c,  the  incisions  for  the  tibio-tarsal  or  Synie's  am- 
putation at  the  ankle-joint.  If  the  incision,  c  c,  from  the  end  of  the 
tibia  to  the  plantar  surface  of  the  heel,  ran  a  little  more  obliquely 
backwards,  it  would  trace  out  the  incision  for  Pirogoff's  amputation  at 
the  ankle-joint. 

Fig.  2. — Syme's  tibio-farsal  disarticulation.  The  completion  of  the 
operation  by  separating  the  tendo  achillis  from  the  os  calcis. 

Fig.  3. — Completion  of  Pirogoff's  amputation.  The  inferior  extrem- 
ities of  the  tibia  and  fibula  removed,  exhibiting  the  general  outline  of 
the  plantar  flap,  with  a  portion  of  the  os  calcis  embedded  in  its  centre. 

Fig.  4. — The  appearance  of  the  stump  after  Pirogoff's  amputation. 

Fig.  5. — Amputation  of  the  leg  in  lower  third,  a  b,  the  extremities 
of  the  flap  formed  by  a  union  of  the  vertical  incision  with  the  circular; 
d,  position  of  posterior  vessel;  e,  peroneal  artery  ;  /,  anterior  tibial 
vessels.     Lenoir's  method. 

Fig.  6. — Circular  amputation  at  the  seat  of  election,  the  upper  third. 
a  b  c,  the  line  of  incision  through  the  skin  for  circular  flap;  d,  circular 
flap  of  skin  turned  up  like  cuff  of  sleeve,  being  from  two  and  a  half 
to  three  inches  in  length — the  knife  dividing  the  muscles  to  the  bone 
at  the  base  of  the  flap. 

Fig.  7. — a  a,  retractor  of  cloth  placed  between  the  bones  to  protect 
the  stump ;  the  position  of  the  saw. 

Fig.  8. — Appearance  of  stump  before  closed,  h,  tibia;  g,  fibula;  b, 
anterior  tibial  artery  and  veins  in  front  of  interosseous  ligament  and 
between  the  bones;  r,  posterior  tibial  vessels  behind  the  tibia;  d,  pero- 
neal artery  and  two  veins  behind  the  fibula;  /,  sural  vessels  for  calf 
muscles. 


Plate  9. 

Fig.  1. — Amputation  of  leg  in  upper  third  by  posterior  flap,  a  b  c, 
line  in  which  the  flap  will  be  cut  by  the  knife  transfixing  the  calf  at  a 
c — the  hand  of  the  surgeon  drawing  back  the  muscles.  The  objection 
to  this  operation  is  the  size  and  weight  of  the  posterior  flap.  After  sec- 
tion of  the  bones  and  removal  of  the  limb,  a  more  useful  and  lighter  flap 
is  made  by  holding  the  flap  upon  the  palm  of  the  hand,  and  slicing  off 
a  thick  layer  of  muscle  from  its  anterior  face. 

Fig,  2  gives  the  anterior  transverse  lines  for  tracing  incisions  in 
amputations  about  the  knee-joint,  n,  fibula;  m,  tibia;  p,  patella;  o, 
femur;  g  h  k,  circular  amputation  of  leg;  d  e  f,  anterior  lino  of  inci- 
sion, where  the  amputation  is  performed  with  a  large  posterior  flap,  as 
in  fig.  1;  ab  c,  anterior  incision  for  disarticulation  at  knee-joint,  as 
seen  in  fig.  4. 

Fig.  3. — Anatomy  of  knee-joint,  a,  inferior  extremity  of  femur  ;  b, 
head  of  tibia;  c,  patella  enveloped  in  the  anterior  ligament  or  tendon 
of  the  quadruceps  extensor  muscle,  called  ligamentum  patella;  ;  d, 
crucial  ligaments;  e,  popliteal  artery,  lying  immediately  upon  and 
behind  the  joint. 

Fig.  4. — Amputation  at  knee-joint  by  posterior  flap.  The  operation 
commenced  by  a  circular  incision  into  the  joint  just  below  the  patella, 
which  extends  through  half  the  circumference  of  the  knee,  a  b  c,  form 
and  extent  of  flap;  p,  patella;  /,  femur;  d  t  g,  line  of  incisions  in 
performing  the  posterior  flap  amputation  of  the  leg  in  uppor  third  or 
seat  of  election. 

Fig.  5. — Amputation  at  knee-joint  by  anterior  flap,  a  b  c,  line  of 
anterior  flap;  t,  anterior  surface  of  tibia  exposed  ;  ;>,  patella;  /,  femur; 
d,  anterior  flap  turned  up.  The  knife  is  passing  through  tho  joint 
between  the  heads  of  the  bones. 


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Pl.ATB    10. 

Fig.  1. — Anterior  and  posterior  flap  amputation  of  the  thigh  in  mid- 
dle third,  cf,  line  of  anterior  flap  ;  b,  anterior  flap  held  up  by  hand  of 
an  assistant.  In  perforating  for  the  anterior  flap  the  operator,  with  hi? 
left  hand,  draws  the  soft  parts  on  the  anterior  surface  of  the  leg  as  much 
forward  as  possible,  so  that  the  anterior  flap  will  comprise  half  of  the 
circumference  of  the  thigh.  The  knife  has  been  again  thrust  through 
the  thigh  and  behind  the  femur,  so  as  to  cut  out  the  posterior  flap,  d. 

Fig.  2. — Appearance  of  stump  after  double  flap  amputation,  e,  ante- 
rior flap ;  /,  posterior  flap,  separated  to  show  the  extremity  of  the  femur 
deeply  embedded  in  the  muscles;  g,  femoral  artery  and  vein  on  inner 
side  of  flap. 

Fig.  3. — Circular  amputation  at  middle  of  thigh,  c,  first  incision 
through  the  skin  ;  d,  incision  through  the  muscles  ;  e,  final  incision  to 
the  bone ;  f,  section  of  the  femur ;  a  a,  retractor  around  the  bone  to 
protect  the  upper  flap,  b. 

Fig.  4. — Appearance  of  stump  after  circular  amputation,  a,  femur  ; 
b,  femoral  artery  and  vein  ;  c,  muscular  vessels. 

Fig.  5. — Amputation  at  hip-joint.  Anatomy  of  the  parts,  c,  point 
of  entrance  of  knife  above  great  trochanter ;  a,  exit  of  the  point  near 
inner  fold  of  the  groin,  the  blade  in  its  passage  over  the  anterior  sur- 
face of  the  hip-joint  and  head  of  the  femur  having  divided  freely  the 
capsule  of  the  articulation ;  a  b  c,  size  and  form  of  anterior  flap. 

Fig.  6. — Amputation  at  hip-joint,  a,  hand  of  assistant  lifting  the 
anterior  flap;  c  c,  femoral  artery  and  profunda  branch;  b,  head  of 
femur  turned  out  of  the  cotyloid  cavity,  the  knife  behind  the  femur 
cutting  out  posterior  flap. 

Fig.  7. — Double  flap  amputation  at  hip-joint  completed.  Size,  form, 
and  direction  of  flaps.  /  /,  the  femoral  artery  and  the  profunda 
branch. 


Plate  11. 

Fig.  1. — Resection  of  the  lower  jaw.  The  incision  for  removing 
half  of  the  bone  from  its  symphysis  to  the  glenoid  cavity,  runs  along 
the  base  of  the  jaw.  a  b  c,  the  flap  dissected  up  and  held  over  the  tem- 
ple by  an  assistant;  d,  the  symphysis  of  the  lower  jaw,  where  the  bone 
has  been  divided  by  the  saw;  e,  the  lower  jaw  forcibly  drawn  out- 
wards so  as  to  expose  for  section  the  pterygoid  and  temporal  muscles, 
and  render  disarticulation,  of  the  jaw  easy. 

Fig.  2. — Removal  of  the  anterior  portion  of  the  jaw,  including  the 
symphysis,  d,  the  incision  passed  through  tho  middle  of  the  lower  lip 
in  the  median  line,  extending  under  the  chin  to  the  hyoid  bone ;  a  b, 
the  ends  of  the  flaps  dissected  up  and  drawn  aside.  The  saw  is  applied 
to  the  lower  jaw  at  the  canine  fossa. 

Fig.  3. — Removal  of  upper  maxillary.  The  line  of  incision  through 
the  cheek  is  seen  in  fig.  4.  The  flap  is  dissected  up  from  the  bone,  and 
the  nasal  cartilages  separated  from  the  nasal  process  of  the  maxilla  : 
the  bone  is  readily  isolated  from  its  intimate  attachment  by  passing 
one  blade  of  a  strong  Liston's  forceps  through  the  mouth,  the  other 
through  the  anterior  nares,  thereby  dividing  the  roof  of  the  mouth  or 
palate  process  of  the  superior  maxillary  bone.  One  blade  of  the  for- 
ceps can  again  be  placed  in  the  upper  part  of  the  nares ;  the  other  in 
the  orbit  to  divide  the  floor  of  the  orbit.  Tho  malar  connection  can  be 
divided  with  the  saw  or  by  the  bone  forceps,  by  placing  one  blade  in 
the  orbit,  the  other  in  the  temporal  fossa. 

Fig.  4  shows  the  curved  line  of  incision  from  tho  zygomatic  arch  to 
the  angle  of  the  mouth ;  also,  how  the  wound  is  dressed  by  several 
points  of  interrupted  suture,  and  how  little  deformity  results  from  this 
resection. 


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Plate  12. 

Fig.  1. — Resection  of  the  shoulder  by  a  deltoid  flap,  d,  tho  flap 
made  from  the  deltoid  muscle  turned  up  upon  the  shoulder;  /;,  head  of 
humerus  isolated  from  the  glenoid  cavity:  /,  chain-saw  passed  behind 
the  head  of  the  bone  in  the  act  of  resecting. 

Fig,  2. — Resection  of  the  shoulder  by  the  straight  incision.  /,  posi- 
tion of  the  clavicle;  c,  accromial  process  of  the  scapula;  a  perpen- 
dicular incision  of  five  inches  in  length  passing  down  to  the  bone,  com- 
mencing at  the  accromial  process ;  d  d,  two  retractors  or  hooks  for 
drawing  aside  tho  soft  parts,  exposing  clearly,  a,  tho  head  of  the  hu- 
merus;/,  resection  of  tho  sternal  end  of  tho  clavicle,  the  soft  parts 
divided  by  an  incision  upon  and  parallel  with  the  clavicle — the  soft 
parts  retracted  to  expose  the  bone. 

Fig.  3. — Resection  of  the  elbow-joint.  1,  2,  3,  4,  of  fig.  4,  marks 
out  extent  and  direction  of  the  incisions;  1,  hand  of  assistant  raising 
the  posterior  flap;  2,  joint  exposed;  3,  saw  applied  to,  4,  the  inferior 
extremity  of  the  humerus. 

Fig.  \. — The  H  incision,  generally  used  in  exposing  the  elbow-joint 
forjresoction  of  the  heads  of  the  bones.  The  method  of  closing  the 
same  by  suture  when  the  section  of  the  bones  is  completed. 

Fig.  5. — Resection  at  the  wrist-joint,  removing  the  styloid  process  of 
the  ulna.  1,  the  flap;  2,  carpal  extremity  of  the  ulna;  3,  the  blade 
of  a  spatula  placed  under  the  bone  to  be  divided,  so  that  the  saw,  4, 
cutting  against  this,  can  not  injure  the  soft  parts. 

Fig.  6. — A  hand,  with  delineations  of  the  bones  of  tho  forearm  and 
carpus.  1,  2,  3,  4,  form  and  extent  of  an  incision  which  will  expose 
the  posterior  surface  of  the  radio-carpal  joint,  and  facilitate  the  remov- 
al of  the  carpal  extremity  of  both  radius  and  ulna. 


Plate  13. 

Fig.  1. — Resection  of  the  hip-joint;  a  straight  incision,  six  inches  in 
length,  on  the  outer  side  of  the  joint,  upon  and  parallel  with  the  femur, 
commencing  about  two  inches  above  the  great  trochanter,  or  on  a  level 
with  the  anterior  superior  spinous  process  of  the  ilium.  The  soft  parts 
drawn  aside  to  expose — a,  the  femur;  b,  the  great  trochanter;  d,  the 
head  of  the  femur. 

Fig.  2. — Resection  of  the  hip-joint  by  means  of  an  external  flap,  cut 
from  below  upwards,  by  transfixion.  1,  the  head  of  the  femur  dis- 
lodged from  the  acetabulum  and  turned  outward,  so  that  a  guard  can 
be  placed  behind  the  head  for  the  protection  of  the  soft  parts  from  the 
saw;  3,  a  chain-saw,  placed  around  the  neck  of  the  femur  for  its  re- 
section. 

Fig.  3. — Resection  of  the  knee-joint.  The  articulation  exposed  by 
making  two  elliptical  incisions  from  one  condyle  to  the  other,  including 
the  patella,  which  is  removed.  1,  a  retractor  or  piece  of  cloth  passed 
around  the  inferior  extremity  of  the  femur  to  retract  the  soft  parts;  2, 
a  guard  placed  behind  the  bono  to  protect  them  from  the  saw ;  S, 
the  extremity  of  the  femur  being  removed  by,  4,  the  saw.  The  t#o 
round  dark  surfaces,  surrounded  by  white  rings,  are  the  articulating 
cups  upon  the  head  of  the  tibia. 

Fig.  4. — Resection  of  the  ankle-joint.  Tho  extremity  of  the  bone  is 
exposed  by  an  L  incision,  made  parallel  with  the  outer  border  of  the 
bone,  and  then  at  right  angles  across  its  head ;  2,  a  chisel,  and  3,  mal- 
let, which  are  the  instruments  used  for  dividing  the  bone.  When  the 
section  of  the  bone  is  effected,  a  knife  divides  the  ligaments  and  com- 
pletes the  isolation. 


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Platb  14. 

Fig.  l.—Strnotn re  of  arteries.  «.  external  or  cellular  coat,  the  (ongh, 
resisting  coat  of  arteries  dissected  up  ;  6,  thick  elastic  muscular  or  mid- 
dle coat,  also  dissected  from  c,  the  inner  or  serous  coat.  Both  the  coats, 
B  and  C,  are  divided  by  the  thread  in  the  application  of  the  ligature. 

Fig.  2. — The  appearance  of  an  artery  after  the  application  of  a  lig- 
ature, c  d,  a  ligature  applied  so  as  to  cut  through  the  inner  and  middle, 
which  are  the  brittle  coats  of  the  artery.  These  coats  are  seen  pucker- 
ed in,  have  become  united,  and  are  continuous  on  each  side  of  the  ves- 
sel ;  6,  clot  of  blood  formed  in  the  upper  portion  of  the  vessel ;  no 
clot  is  seen  below  tho  ligature  ;  a,  the  first  collateral  branch,  which  leads 
the  blood  through  a  circuitous  route,  and  will  take  the  place  of  the 
main  channel  obliterated  by  the  ligature. 

Fig.  3. — An  artery  obliterated  by  a  ligature,  c,  a  fibrous  band  form- 
ed in  the  former  site  of  the  ligature;  b  b,  fibrinous  clots  in  ends  of  the 
artery  for  the  permanent  occlusion  of  the  vessel. 

Fig.  4. — Occlusion  of  the  popliteal  artery,  a,  showing  how  the 
branches,  6  6  6,  given  off  both  above  and  below  the  obliterated  portion, 
enlarge  and  communicate,  so  as  to  carry  on  the  collateral  circulation, 
and  restore  it  to  the  natural  channel  below  the  obstruction.  Also  ex- 
plains bow  the  collateral  circulation,  bringing  blood  to  the  lower  por- 
tion of  a  divided  artery,  induces  secondary  hemorrhage. 

Fig.  5. — Mode  of  securing  an  artery  after  amputations,  by  using  a 
tenaculum,  r,  loop  of  ligature  upon  the  instrument  ready  to  be  applied 
to  the  vessel. 

Fig  6  shows  how  the  femoral  artery  should  be  compressed  by  the 
thumbs  of  an  assistant  in  amputations  of  the  inferior  extremity.  The 
limb  is  grasped  by  both  hands,  and  one  thumb  placed  upon  the  other. 
Pressure  is  only  made  by  one  thumb  at  a  time:  when  the  lower  one  be- 
comes fatigued,  pressure  is  made  by  the  upper  upon  the  lower;  in  this 
way  they  relieve  each  other. 

Fig.  7. — The  use  of  the  simplest  form  of  field  tourniquet,  composed 
of  a  bandage  or  folded  handkerchief  with  a  knot  in  it.  The  knot  is 
placed  over  the  course  of  the  femoral  artery,  and  the  bandage  tight- 
ened by  twisting  it  with  a  piece  of  stick 

Fig.  8. — The  mode  of  applying  the  icrew  tourniquet 


Plate  15. 

Fig.  1. — Anatomy  of  the  hand,  showing  the  course  and  relations  of 
the  termination  of  the  radial  artery.  1,  band  of  annular  fascia,  which 
binds  down  the  tendons  at  the  wrist;  2,  extensor  ossis  metacarpi  pol- 
licis;  3,  extensor  primi  internodii  pollicis;  4,  extensor  secundi  inter- 
nodii  pollicis  muscle;  a,  radial  artery  in  the  depression  between  the 
tendons  upon  the  back  of  the  thumb. 

Fig.  2. — The  incision,  an  inch  long,  made  in  a  line  parallel  with  the 
index  finger,  and  necessary  for  exposing  the  radial  artery  on  the  back 
of  the  hand,    a,  the  artery  ;  6,  the  ligature  passed  behind  it. 

Fig.  3. — Anatomy  of  the  forearm  and  hand,  showing  the  course  and 
relations  of  the  radial  and  ulna  vessels,  a,  brachial  artery,  accompa- 
nied by  b,  median  nerve ;  c,  median  basilic  vein  at  the  bend  of  the 
elbow,  used  in  phlebotomy;  d,  aponeurotic  expansion  of  the  tendon 
of  the  biceps  muscle,  under  which  passes  the  brachial  artery,  and  over 
which  lies  the  median  basilic  vein.  As  this  vein  is  separated  from  the 
brachial  artery  at  the  bend  of  the  elbow  only  by  the  aponeurotic  expan- 
sion of  the  biceps  tendon,  the  artery  may  be  readily  injured  by  blood- 
ing carelessly  in  this  vein.  Under  this  tendon  the  brachial  artery  bi- 
furcates into  radial  and  ulna,  g,  k,  curved  course  of  the  ulna  artery, 
accompanied  by  two  veins,  and  h,  the  ulna  nerve;  I,  the  continuation 
of  the  ulna  artery  under  the  annular  ligament,  to  form  the  superficial 
palmar  arch,  with  branches  passing  to  each  finger ;  i,  tendon  of  the 
flexor  carpi  ulnaris  muscle  upon  its  outer  side ;  j,  the  tendon  of  the 
flexor  sublimis  digitorum  upon  the  inner  sido  of  the  vessel,  the  artery 
always  lying  between  these  two  muscles,  being  more  or  less  covered 
by  the  flexor  carpi  ulnares ;  p  t,  radial  artery,  running  a  straight  course, 
and  accompanied  by  r  *,  two  veins ;  q,  tendon  of  the  supinator  longus 
muscle  upon  its  outer  side;  on  its  inner  sido  is  the  flexor  carpi  radialis 
muscle.  Either  of  those  tendons  are  used  as  a  guido  for  finding  the 
artery. 

Fig.  4. — Tracing  of  the  brachial  artery  with  its  branches,  the  radial 
and  ulna,  through  the  arm,  forearm,  and  hand,  with  size  and  direction 
of  the  incisions  required  in  ligating  these  arteries  in  the  lower  and 
uppor  part  of  the  forearm,  a,  skin;  b,  cellular  tissue;,  c,  ulna  norve; 
d,  accompanying  vein ;  a,  ulna  artery  elevated  upon  the  aneurism 
needle. 


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Plate  16. 

Fig.  1. — Position  and  relations  of  the  brachial  vessels  in  the  arm. 
A,  brachial  artery  as  it  appears  from  the  axilla  to  the  elbow  ;  /•'.  the 
large  brachial  vein  which  accompanies  it ;  B,  the  basilic  vein,  also  ac- 
companying the  artery;  E,  the  median  nerve  lying  above  upon  the 
outer  side  of  tho  artery,  crossing  its  course  in  the  middle  of  the  arm,  to 
run  upon  its  inner  side,  near  the  elbow;  H,  inferior  profunda  branch  of 
the  humeral  artery,  accompanied  by  A',  the  ulna  nerve;  C,  coraco- 
braohialis  muscle;  T>,  biceps  muscle,  the  package  containing  the  brach- 
ial vessels  and  nerves  always  found  on  the  inner  border  of  this  mus 
cle;  a,  aponuerotic  fascia  from  the  tendon  of  this  muscle,  forming  a 
bridge  at  the  elbow  under  which  the  brachial  artery  passes. 

Fig.  2. — The  direction  of  the  brachial  artery  traced  upon  tho  inner 
side  of  the  biceps  muscle,  with  the  incision  for  its  ligation,  both  in  upper 
and  lower  portion  of  the  arm.  a,  the  artery  elevated  upon  c,  tho 
grooved  director ;  b,  the  sheath  of  the  vessel. 

Fig.  3. — Exposure  of  the  axillary  space.  1,  the  pectoralis  muscle, 
forming  the  anterior  boundary  of  tho  space;  3,  the  latissimus  dorsi 
muscle,  forming  the  posterior  wall ;  4,  biceps  and  coraco-brachialis  mus- 
cles on  the  outer  side  of  the  arm  ;  5,  the  origin  of  the  triceps  muscle  ;  6, 
superficial  fascia  which  covers  and  binds  down  all  of  the  structures  of 
arm  ;  k,  the  axillary  artery,  appearing  between  the  median  nerve,  (I, 
and/',  the  ulna  nerve;  r,  scapula  branches  of  the  axillary  artery;  gt 
axillary  vein;  e,  the  internal  cutaneous  nerve. 

Fig,  4. — The  position  of  the  incision  for  securing  the  axillary  artery, 
being  in  a  line  with  the  inner  border  of  the  coraco-brachialis  and  biceps 
muscles,  and  corresponding  to  the  junction  of  the  anterior  and  middle 
thirds  of  the  axillary  space,  b,  the  axillary  artery  upon  the  grooved 
director  ;  d,  axillary  vein  ;  o,  median  ner\ v  ;  < ,  ulna  nerve. 


Tt 


Plate  17. 

Fig.  1. — Anatomy  of  the  dorsum  of  the  foot,  with  course  of  the  dor- 
salis pedis  artery,  the  continuation  of  tho  anterior  tibial  artery.  A, 
dorsalis  pedis  artery  accompanied  by  its  vein  bound  down  by  1,  the  an- 
nular ligament,  having,  2,  the  tendon  of  the  extensor  pollieis  pedis  on 
its  inner  side,  and  4,  3,  the  extensor  communis  digitorum  upon  its  outer 
side. 

Fig.  2. — Incision  upon  the  ankle  for  securing  the  dorsalis  pedis  arto- 
ry  in  a  line  drawn  from  midway  between  the  malleoli  to  the  space  be- 
tween big  toe  and  second  toe. 

Fig.  3. — Relations  of  the  anterior  and  posterior  tibial  arteries.  4, 
tibialis  anticus  muscle,  hooked  forward  ;  5,  flexor  communis  digitorum, 
drawn  outward  ;  A,  anterior  tibial  artery,  with  B,  accompanying  vein> 
lying  deeply  upon  the  interosseous  membrane  between  these  muscles; 
8,  the  extensor  pollieis  pedis  assuming  the  same  position  on  the  outer 
side  of  the  inferior  half  of  the  anterior  tibial  artery  as  the  flexor  com- 
munis did  in  the  upper  half  of  the  leg;  c,  anterior  tibial  nerve  on  the 
outer  side  of  the  artery;  9,  posterior  tibial  artery  drawn  out  from  beneath 
the  gastrocnemius  and  soleus  muscles. 

Fig.  4. — 1,  2,  incisions  made  in  a  line  drawn  from  midway  between  the 
head  of  tibia  and  fibula  above,  to  a  point  on  the  back  of  the  foot  between 
the  malleoli;  A,  the  artery  hooked  up  ;  3,  incision  made  upon  the  inner 
border  of  the  muscles  of  the  calf,  for  securing  the  posterior  tibial  arte- 
ry ;  A,  the  artery  ;  b,  the  posterior  tibial  nerve. 


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Plate  18. 

Fig.  1. — Relations  of  the  posterior  tibial  artery,  A,  lying  between  tho 
superficial  and  deep  layers  of  muscles  upon  the  back  of  the  leg,  covered 
in  the  upper  half  of  its  course  by  9,  the  gastrocnemius  and  soleus  mus- 
cles, and  lying  upon  8,  the  common  flexor  of  the  toes.  In  the  lower 
part  of  the  leg  the  posterior  tibial  artery  lies  between  6,  the  tendo  achil- 
lis,  and  7,  the  common  flexor  of  the  toes,  which  separate  the  vessel  from 
the  face  of  the  tibia;  C,  the  posterior  tibial  nerve  which  follows  the 
course  of  the  arter}r ;  B,  the  tibial  veins,  two  of  which  accompany  the 
vessel 

Fij.  2. — The  position  of  incisions  for  exposing  the  posterior  tibial 
artery  in  its  upper,  middle,  or  lower  third,  in  a  line  drawn  from  the 
inner  and  posterior  edge  of  the  head  of  the  tibia  to  a  point  midway  be- 
tween the  tendo  achillis  and  inner  malleolus;  3,  an  incision  through  the 
skin  ;  6,  the  superficial  fascia  ;  d,  the  inner  bordor  of  the  soleus  muscle, 
separated  from  its  attachment  to  the  tibia  and  drawn  outward ;  A,  the 
posterior  tibial  artery,  accompanied  by  two  veins,  and  having  the  pos- 
terior tibial  nerve  in  its  immediate  neighborhood. 


Plate  19. 

Fig.  1. — The  relations  of  the  iliac  arteries,  passing  through  the  up- 
per edge  of  the  pelvic  cavity  to  be  continuous,  as  femoral  artery,  upon 
the  thigh.  1,  portion  of  abdominal  walls  ;  2,  anterior  superior  spinous 
process  of  the  ilium;  3,  sartorius  muscle;  4,  psoas  magnus  muscle;  5, 
iliacus  internus  muscle,  upon  the  lower  portion  of  which,  as  a  bed.  lies 
the  iliac  vessels  and  nerves  ;  A,  inferior  portion  of  the  aorta  bifurcat- 
ing into  E,  common  iliac  artery,  which  in  turn  bifurcates,  after  a  course 
of  two  and  a  half  inches,  into  D,  the  internal,  and  //,  the  external  iliac 
arteries.  Just  before  reaching  Poupart's  ligament  the  external  iliac  ar- 
tey  gives  off  two  branches — c,  epigastric  artery,  and  e,  the  circumflex 
ilii ;  G,  anterior  plexus  of  femoral  nerves  lying  upon  the  outer  side  of 
the  artery  ;  F,  the  common  iliac  vein,  passing  under  the  iliac  artery  to 
take  up  a  position  upon  its  inner  side;  K,  spermatic  cord,  with  testicle 
appended. 

Fig.  2. — Continuation  of  fig.  1,  showing  the  course  of  the  femoral 
artery  A,  through  the  thigh,  accompanied  by  C,  the  femoral  vein,  and 
F,  the  internal  cutaneous  nerves  :  one  of  these,  in  immediate  juxtaposi- 
tion with  the  femoral  vessels,  passes  under  the  tendinous  bridge,  2,  in  the 
adduotor  magnue muscle — the  other  runs  over  the  bridge,  to  become  sub- 
cutaneous and  supply  the  skin  on  the  inner  and  anterior  face  of  the  log 
and  foot  ;  tho  sartorious  muscle  is  drawn  upward  and  outward,  so  as 
to  expose  the  femoral  vessel  running  under  it;  </,  the  saphenous  Vein, 
emptying  into  the  femoral  vein,  through  the  saphenous  opening  in  tho 
fascia  lata,  and  ou  a  level  with  the  origin  of  the  profunda  femoris  arte- 
ry; 1,  Poupart's  ligament,  forming  the  base  of  Scarpa's  triangle. 

Fiij.  8  traces  the  course  of  the  femoral  artery,  and  the  direotion  of 
incisions  necessary  for  exposing  it  in  any  part  of  its  course.  These  in- 
cisions will  be  found  in  a  line  drawn  from  the  middle  of  Poupart's  liga- 
ment to  the  inner  and  posterior  edge  of  the  inner  condyle  of  the  femur. 
The  three  incisions  upon  the  thigh  lie  in  such  a  line;  on  tho  groin,  tho 
incision  is  at  right  angles  to  the  course  of  the  artery  ;  a,  incision  in 
skin;  b,  superficial  fascia;  <•,  sheath  of  tho  vessels;  d,  femoral  m  in  M 
inner  side  of  artery  ;  A,  femoral  artery,  raised  upon  the  grooved  di- 
rector. 


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Plate  20. 

Fig.  1. — Anatomy  of  the  nock.  1,  the  sternohyoid  and  thyroid  mus 
cles,  covering  the  trachea;  2,  the  oino-hyoid  muscle,  running  obliquely 
across  tho  neck  from  the  scapula  to  the  hyoid  bone,  and  forming  two 
triangles  of  the  deep  cervical  region — the  superior  and  inferior  cervi- 
cal triangles  :  3,  the  sterno-cleido-mastoid  muscle,  severed  in  its  lower 
third — a  portion  drawn  over  the  clavicle,  the  upper  portion  drawn  aside 
by  a  hook,  in  order  to  expose  the  deep  region  of  the  neck  which  is 
covered  in  by  this  muscle  ;  4,  the  masseter  muscle,  attached  to  the  lower 
jaw  ;  A,  common  carotid  artery,  deeply  seated  below  where  covered  by 
the  clavicle  and  stemo-clcido-rnastoid  muscle,  and  becoming  more  super- 
ficial after  passing  beneath  the  omo-hyoid  muscle.  This  artery  bifur- 
cates On  a  level  with  the  upper  border  of  the  thyroid  cartilage  into  inter- 
nal and  external  carotid,  tho  external  branch  coursing  upward  in  front 
of  the  ear;  B,  the  internal  jugular  vein,  running  along  the  outer  and 
posterior  surface  of  the  artery,  and  being  much  larger  than  the  carotid 
vessel,  it  oarers  it  when  distended  with  blood :  V,  pneumogastric 
nerve,  running  in  the  BheaiD  of  the  vessels  between  and  behind  them  ; 
D,  bifurcation  of  the  internal  jugular  vein,  with  branches  correspond- 
ing to  the  bifurcations  of  the  carotid  vessel  :  E,  facial  vessels  ;  F,  su- 
perior thyroid  artery,  the  first  branch  from  the  external  carotid;  H,  lin- 
gual artery. 

Fig.  2  represents  course  of  the  common  carotid  and  some  of  the 
branches  of  the  external  carotid  artery,  a,  incision  for  ligating  the  com- 
mon carotid  artery  in  the  middle  of  the  neck  ;  b,  incision  for  exposing 
the  lingual  artery:  e,  incision  exposing  the  facial  artery  as  it  runs  over 
the  lower  jaw,  immediately  in  front  of  the  insertion  of  the  masseter 
muscle:  d,  ligation  of  the  temporal  artery  or  terminal  branch  of  the 
external  carotid,  in  front  of  the  ear. 

/'/■/.  3. — Anatomy  of  the  lower  portion  of  the  neck  and  upper  portion 
of  the  chest.  1,  the  clavicle:  2,  the  great  pectoral  mUBcle  attached  to  the 
clavicle;  -1,  stern-cleido-mastoid  muscle;  6,  deltoid  muscle  ;  7,  c<  ranoid 
]M.rti<>n  of  the  pectoralis  minor-  A.  subclavian  artery,  arching  through 
the  subclavicular  region,  to  be  continuous  as  axillary;  It,  axillary  vein, 
continuous  as  subclavian,  lying  upon  the  inferior  and  outer  side  of  the 
artery,  and  receiving  the  cephalic  vein,  (',  from  the  arm  ;  />,  brachial 
plexat  of  nerves  running  behind  and  posterior  to  the  artery  :  n,  scapu- 
lar I. ranch  of  the  subclavian  artery,  running  across  the  root  of  the  neck; 
rior  thyroid  artery,  ascending  from  the  subclavian. 

/>■!.  L— -The  two  fcnoMomi  reejuirud  in  exposing  the  subclavian  and 
axillary  arteries.  2,  incision  four  inches  long,  parallel  with  and  just 
above  the  clavicle  :  a.  subclavian  artery:  h,  the  subclavian  vein  on  in- 
ner sH>  r,  the  brachial  |  ■  outer  side  of  ar- 
tcrx  1.  incision  below  and  parallel  with  the  clavicle  for  exposing  tlie 
axillary  artery;  a,  artery ;  /-,  axillary  voin  upon  it-    Utsjssr  and  ■ 

sci.  . 


Plate  21. 

Fig.  1. — Anatomy  of  the  head.  The  scalp  and  skull  removed  from 
the  outer  half  of  the  head,  exposing  the  brain  enveloped  in  its  menin- 
ges— the  thickness  of  the  scalp  and  skull  is  distinctly  seen ;  b  b  b  is  the 
prolongation  of  the  dura  mater,  called  the  falx  cerebri,  between  the 
folds  of  which  is  contained  the  superior  longitudinal  sinus  ;  G  D,  large 
lateral  sinus  of  the  brain  which,  upon  its  exit  from  the  skull  at  the  fora- 
men lascerum  posterius,  forms  the  origin  of  the  internal  jugular ;  a  a  a, 
branches  of  the  arteria  meningia  media,  ramifying  over  the  surface  of 
the  brain,  being  partially  lodged  in  grooves  in  the  inner  face  of  the 
temporal  bone. 

Fig.  2  shows  the  application  of  the  trephine  in  depressed  fractures  of 
the  skull,  a  a  a  a,  the  four  corners  of  the  crucial  flap  dissected  up  and 
turned  out  so  as  to  expose  the  skull.  The  crown  of  the  trephine  is 
applied  to  the  bone,  and  the  hand  of  the  operator  grasps  the  handle  in 
such  a  way  as  to  permit  of  rotation,  while  the  index  finger  steadies  the 
instrument. 

Fig.  3.— A  fracture  of  the  skull,  with  isolated  fragment.  A  four- 
sided  flap  has  been  dissected  up  so  as  to  expose  the  injury,  and  the  loose 
fragment  has  been  seized  by  a  strong  forceps,  and  is  being  extracted. 

Fig.  4  shows  the  stellated  fracture  produced  by  a  concentration  of 
the  force  causing  the  injury.  A  small  portion  of  the  bone  has  been  re- 
moved to  facilitate  the  application  of  the  lever,  so  as  to  elevate  the 
depressed  fragments  and  restore  them  to  their  proper  position. 


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Pi.ati:  22. 

Fig.  1  represents  the  uianncr  of  holding  t  lie  Bcrotum  in  operating  for 
hydrocele,  so  as  to  make  the  sac  tense  by  forcing  all  tho  scrum  to  the 
most  dependent  portion  of  the  scrotal  sac.  As  the  testicle  is  adherent 
to  the  back  of  the  sac,  the  forcing  of  the  fluid  in  front  throws  a  thick  layer 
of  serum  in  front  of  the  testicle,  shielding  it  from  injury  when  the  sac 
is  punctured  by  tho  trocar.  This  figure  also  shows  how  the  trocar 
should  be  held  by  the  surgeon. 

The  following  plates  show  the  various  methods  used  in  obliterating 
the  enlarged  veins  in  the  disease  called  varicocele: 

Fig.  2. — Incision  over  the  spermatic  cord  at  the  junction  of  the  scro- 
tum with  the  groin,  and  isolation  of  the  spermatic  artery  for  ligation  in 
varicocele.  The  incision  extends  through  the  skin,  cellular  tissue,  su- 
perficial fascia,  and  proper  fascia  of  the  cord,  separating  the  elements 
of  the  spermatic  cord  and  permitting  the  spermatic  artery  to  be  secured. 

Fig.  3  shows  tho  operation  of  applying  a  ligature  to  the  spermatic 
vessels  subcutaneously.  c,  scrotum;  b,  enlarged  cord,  under  which  a 
double  thread  has  been  passed,  leaving  out  the  noose,  a. 

Fig.  4  shows  the  subcutaneous  application  of  a  double  ligature.  One 
double  thread  passes  under  the  other  over  the  cord,  the  ends  of  one 
passing  respectively  through  the  noose  of  the  other,  so  that,  when  firm 
traction  is  made,  as  in  fig.  5,  all  the  vessels  are  compressed,  and  will  be 
finally  obliterated.  In  fig.  4  the  vas  deferens,  b,  or  spermatic  tube  from 
the  testicle,  is  not  included  in  the  ligature. 

Fig.  6  exhibits  the  enlarged  convoluted  condition  of  the  spermatic 
veins  in  varicocele.  A  pin,  a,  has  been  passed  behind  these  enlarged 
vessels,  b. 

Fig.  1  shows  the  position  of  the  pin,  a,  transfixing  the  scrotum,  with 
6  6,  a  strong  thread  wound  tightly  in  figure  of  8  around  the  pin,  and 
compressing  the  vessels  between  the  pin  and  the  thread. 


Pi  am 

l'i-tula  in  ano,  with  method  of  operating  for  obtaining  a  radical  cure. 

Fig.  I  exhibits   the  appearances  of  internal   ii Btpleti  fistula,      r, 

rectum  :  /,  fistulous  sac  in  the  surrounding  cellular  tissue,  with  an  ori- 
fice discharging  the  secretion  of  the  fistula  into  the  bowel,  above  the 
sphincter  muscle. 

2  indicates  an  incomplete  external  fistula,  r,  cavity  of  rectum ; 
>'.  the  irregular  sac  of  a  chronic  abscess,  located  in  the  loose  cellular 
tissue  around  the  rectum,  having  ;in  external  orifice,  O,  from  which  a 
thin  discharge  daily  escapes.  Although  the  fundus  of  this  sac  Lies  in 
juxtaposition  with  the  bowel,  and  may  he  separated  from  it  only  by  the 
thickness  of  the  mucus  membrane,  it  has  no  communication  with  the 
bowel. 

Fig.  '■'<  shows  how  ■  complete  tistula  in  ano  has  an  orifice,  a,  commu- 
nicating with  the  cavity  of  the  bowel,  by  which  pus  or  the  M  ration 
from  the  fistula  is  not  only  thrown  into  the  bowel  to  oscape  by  stool, 
but  gases,  and  even  fecal  matter,  can  escape  by  it  and  through  the  fistu- 
la, to  appear  at  b.  the  outer  orifice  or  exit  upon  the  buttock. 

Fi<j.  4  shows  how  the  silver  flexible  probo  is  pastel  into  the  bowel 
during  the  operation  for  fistula  in  ano.  ,-,  oavitj  of  rectum,  with  the  in- 
dex linger  of  the  lefl  hand  of  the  surgeon  passed  up  into  it;  »,  a  silver 
probo  entered  :it  /.,  the  outer  orifice,  and  passed  along  tho  fistula  through 
((,  the  inner  orifice,  until  it  is  forced  well  into  the  bowel,  when  readily 
felt  by  the  linger;  «,  the  interval  of  tissue  to  be  divided  by  the  knife, 
which  lies  between  the  probe  and  the  finger. 

/  ig.  5. — The  parts  as  above.  The  finger  has  been  hooked  over  the  end 
of  tho  probe,  and  has  drawn  the  bulb  out  of  the  anus  and  lodged  it 
upon  the  opposite  bnttook.  A  sharp-pointed  bistoury.  < .  is  now  run  into 
the  groove  of  the  probe  in  order  to  >U\  i.i<-  t,  the  Lnton  ening  tisau< 
tainingthe  sphincter  muscle,  which  is  the  important  structure  requiring 
division. 

Fig.  6. — Tho  position  of  the  patient  during  the  operation  for  fistula 
in  ano.  Tin-  hand  of  an  assistant  separates  the  buttook,  and  . 
perfectly  the  fistula,  with  the  anus:  the  surgeon  either  passes  the  probe 
as  in  fig.  5,  and  ante  upon  it,  or  passes  the  index  linger  of  the  left  hand 
in  the  anus,  and  pushing  a  probe-pointed  bistoury  through  the  fistula 
into  tho  bowel,  keeps  his  linger  upon  the  extremity  of  the  blade,  while 
ho  makes  it  cut  through  the  intervening  septum. 


FIG  I 


F     I      0  Z 


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FIG  3 


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Mode  afmahn/f  tatenam,viA  adhesive  jihuter 


f      i     c  .       a . 


I?va/i*  §  Csasn'M*  triwffcfrm,  S-  C 


Plate  24. 

Fig.  1. — An  angular  splint  for  the  arm,  with  screw  for  flexing  and 
extending  the  splint — an  excellent  form  of  splint  for  straightening  con- 
tracted limbs,  or  stiffened  elbow-joints. 

Fig.  2. — A  straight  splint  for  treating  fractures  of  the  inferior  ex- 
tremity. 1,  2,  bands  of  adhesive  plaster  applied  around  the  upper  part 
of  thigh,  and  secured  in  position  bj-  S,  a  circular  band  of  adhesive  plas- 
ter ;  counter-extension  is  made  by  means  of  these  strips;  4,  broad  strips 
of  adhesive  plaster,  to  be  attached  to  each  side  of  the  leg  from  the  foot 
to  the  knee,  and  tied  under  the  foot;  5,  the  screw,  for  drawing  the  leg 
downward,  and  making  extension  by  traction  upon  the  adhesive  bands. 

Fig.  3  shows  more  satisfactorily  how  the  adhesive  plaster  is  applied 
for  making  extension  in  fractures — two  broad  strips  attached  to  the  in 
ner  and  outer  face  of  the    leg,  and  secured  by  two  or  three  circular 
bands. 

Fig.  4. — Amesbu'ry's  splint,  or  inclined  plane,  for  treating  fractures 
of  the  leg  or  thigh,  showing  also  the  mode  of  application.  By  means 
of  the  screw  behind  the  knee,  which  flexes  or  extends  the  splint,  the 
apparatus  becomes  very  useful  in  correcting  deformities  from  contracted 
limbs. 

Fig.  5. — An  excellent  form  of  double  inclined  plane  for  treating  all 
cases  of  fracture  of  the  lower  extremity. 

Fig.  6. — Two  simple  forms  of  wooden  stumps  to  be  worn  after  auipu- 
tatiou  of  the  inferior  extremity. 


l'i 


Plate  25. 

Fig.  3. — Posterior  wire  splint  of  Mayor.  M,  foot-piece ;  j,  support 
for  the  leg  ;  D,  for  thigh  ;  C,  the  joint  behind  the  knee.  This  splint  is 
made  of  stout  wire,  with  a  fine  wire  passed  from  side  to  side,  forming 
an  open  platform  for  supporting  the  limb. 

Fig.  2. — The  application  of  Mayor's  posterior  wire  splint,  secured 
to  the  limb  by  bands  or  soft  handkerchiefs,  folded  in  form  of  cravat. 
One  passing  around  the  ankle,  K  L  M,  secures  the  foot  to  the  foot-piece 
of  the  splint :  one,  H  f,  attaches  the  leg  firmly  to  the  wire  ;  the  handker- 
chief,^, secures  the  thigh  firmly  to  the  splint,  while  B  B  C  passes  around 
the  loins  and  attaches  the  upper  portion  of  the  apparatus  to  the  trunk 
— a  very  necessary  band  for  the  comfort  of  the  patient  and  the  suc- 
cessful treatment  of  the  case.  N  N,  0  0,  the  two  suspending  cords 
which,  uniting  in  one,  allows  the  limb  to  be  suspended  from  the  ceiling 
or  top  of  the  bedstead.  The  advantage  of  this  splint  is  its  easy  and 
rapid  application,  giving  but  little  pain,  as  it  requires  but  little  manip- 
ulation of  the  fractured  limb.  It  also  exposes  the  entire  surface  for 
inspection,  or  any  wound  for  treatment,  while  at  the  same  time  it  gives 
a  steady  support  to  the  entire  member. 

Fig.  1. — The  application  of  Mayor's  posterior  wire  splint  to  a  fract- 
ure of  the  leg,  permitting  the  patient  to  get  out  of  bed,  and  to  amuse 
himself  in  many  ways,  without  suffering  pain  or  interfering  with  the 
progress  of  the  cure. 


Pi    zs 


